tag:theconversation.com,2011:/ca/topics/health-rationing-5350/articlesHealth rationing – The Conversation2021-11-11T05:14:21Ztag:theconversation.com,2011:article/1716692021-11-11T05:14:21Z2021-11-11T05:14:21ZPeople who choose not to get vaccinated shouldn’t have to pay for COVID care in hospital<figure><img src="https://images.theconversation.com/files/431422/original/file-20211111-27-1tk1ujl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/healthcare-worker-protective-equipment-performs-coronavirus-1753344953">Shutterstock</a></span></figcaption></figure><p>When I went out in Melbourne for a coffee with a friend earlier this week, the waiter verified my vaccination status before allowing me to sit down. But for the unvaccinated in Victoria and New South Wales, it’s a case of no clubbing, no coffee catch-ups, no movies. </p>
<p>Many employers have even gone beyond the government-mandated minimum and required all staff to be vaccinated as part of <a href="https://ozsage.org/working_group/business/">ensuring a safe workplace</a>.</p>
<p>These mandates are designed to reduce the number of COVID-19 outbreaks and their consequences as Australia’s “lockdown states” open up. Introducing different rules for the vaccinated and the unvaccinated also gives people an incentive to get vaccinated as soon as possible. </p>
<p>Singapore went a step further this week, announcing people <a href="https://www.moh.gov.sg/news-highlights/details/calibrated-adjustments-in-stabilisation-phase_8Nov20210%E2%80%99">who are unvaccinated by choice</a> will have to pay for their own health care. </p>
<p>This isn’t the right way to encourage vaccination, and shouldn’t be replicated in Australia.</p>
<h2>What if an unvaccinated Singaporean gets COVID?</h2>
<p>Singapore has a complicated system of health insurance which includes “<a href="https://www.moh.gov.sg/cost-financing/healthcare-schemes-subsidies/medisave">medical savings accounts</a>” from which people can pay for their health care and keep the balance for <a href="https://www.cpf.gov.sg/member/account-services/providing-for-your-loved-ones/making-a-cpf-nomination">distribution to their estate when they die</a>.</p>
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Read more:
<a href="https://theconversation.com/creating-a-better-health-system-lessons-from-singapore-30607">Creating a better health system: lessons from Singapore</a>
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<p>Under the new policy, unvaccinated Singaporeans will still get care, but could be substantially out-of-pocket when or if they recover. COVID-related hospital care can be expensive and so could easily wipe out a medical savings account balance. </p>
<p>Singapore’s new policy is implemented with the best intentions – to reduce demand on a stretched health system by reducing the number of avoidable hospital admissions among the unvaccinated. </p>
<h2>Why some are calling for us to follow Singapore’s lead</h2>
<p>Despite high rates of vaccination in Australia (<a href="https://covidbaseau.com/">more than 80% of over-16s are double-dose vaccinated</a>) and COVID cases trending down, hospitals in NSW and Victoria are still under pressure. </p>
<p>And even though the unvaccinated are only a small proportion of the population in those jurisdictions, <a href="https://www.health.vic.gov.au/media-releases/coronavirus-update-for-victoria-10-november-2021">almost everyone</a> with COVID in an intensive care unit bed is unvaccinated.</p>
<p>Former NSW premier <a href="https://www.news.com.au/lifestyle/health/health-problems/you-pay-for-your-wilful-stupidity-bob-carr-calls-for-unvaccinated-to-be-denied-free-healthcare/news-story/4d8cdb8319d20dda21fbc1acf0d7a5e3">Bob Carr endorsed the Singaporean approach</a> and called for Australia to follow suit. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1457977588299689987"}"></div></p>
<p>Others have <a href="https://www.crikey.com.au/2021/11/11/vaccine-refuseniks-need-to-pay-for-the-pressure-their-actions-put-on-public-hospitals/">hopped on the bandwagon</a>. I strongly disagree.</p>
<h2>The importance of universal coverage – for everyone</h2>
<p>Australia’s Medicare system provides universal coverage for medical and public hospital care. It’s not a system just for the poor, or just for the well-behaved. It promotes social solidarity. </p>
<p>Widespread vaccination was always going to be the best way out of lockdowns and the path to reopening Australian and state borders. Grattan Institute’s <a href="https://grattan.edu.au/report/race-to-80/">Race to 80</a> report supported vaccine passports and other strategies to encourage vaccination. But <a href="https://www.sciencedirect.com/science/article/pii/S0264410X15003564">how far</a> should these nudges to increase vaccination rates go?</p>
<p>Undermining Medicare’s universality – by excluding the unvaccinated from its financial protection – is a bridge too far. </p>
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<img alt="Hospital trolly in a dark corridor." src="https://images.theconversation.com/files/431427/original/file-20211111-13-tdkl73.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/431427/original/file-20211111-13-tdkl73.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=340&fit=crop&dpr=1 600w, https://images.theconversation.com/files/431427/original/file-20211111-13-tdkl73.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=340&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/431427/original/file-20211111-13-tdkl73.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=340&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/431427/original/file-20211111-13-tdkl73.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=428&fit=crop&dpr=1 754w, https://images.theconversation.com/files/431427/original/file-20211111-13-tdkl73.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=428&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/431427/original/file-20211111-13-tdkl73.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=428&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Unvaccinated Australians should have access to free hospital care, just like the rest of the population.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/empty-hospital-hallway-611606933">Shutterstock</a></span>
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<p>Sure, I think anti-vaxxers should know better; their vaccination status poses a risk to themselves and all of us.</p>
<p>But the Singaporean policy statement has hidden in it the root of the problem – it is targeted at those who are unvaccinated by choice.</p>
<p>The evidence shows vaccination in Australia – like other aspects of health care – <a href="https://csrm.cass.anu.edu.au/sites/default/files/docs/2021/9/Determinants_of_COVID-19_vaccination_and_views_of_parents_about_vaccination_of_children_in_Australia_-_August_2021_-_For_web.pdf">suffers from a distinct social gradient</a>. Poorer people and those less well educated have lower rates of vaccination. </p>
<p>This may be because their lives are less well organised, and they can’t take time off from precarious employment to get vaccinated. It may be they are more susceptible to misinformation campaigns. </p>
<p>Whatever the case, their “choice” may not be a fully informed and freely made one. </p>
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Read more:
<a href="https://theconversation.com/just-the-facts-or-more-detail-to-battle-vaccine-hesitancy-the-messaging-has-to-be-just-right-155953">Just the facts, or more detail? To battle vaccine hesitancy, the messaging has to be just right</a>
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<h2>Failures in the government’s vaccination program</h2>
<p>Penalising unvaccinated Australians by excluding them from Medicare would be a convenient way of shifting responsibility on to individuals for government failures. </p>
<p>Early on, the federal government did not make vaccination easy to get. And the government has failed to ensure the whole population has all the information it needs to make good vaccination decisions. </p>
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<p>If the unvaccinated were barred from Medicare, these government failures would magically become a problem for a small number of individuals, and no longer a political failure.</p>
<h2>If we exclude unvaccinated people, where to next?</h2>
<p>If we exclude the unvaccinated from Medicare’s protection today, <a href="https://academic.oup.com/phe/article/12/2/133/5528519">tomorrow we might exclude the smoker, the day after the drinker</a>, or the person who did not go out jogging, or has not taken up private health insurance.</p>
<p>Hospital emergency department staff regularly have to care for a drink driver and their victim on the same day. They have an ethical obligation to treat everybody equally. Similarly, as frustrating as it might seem, the health system must still be there for the unvaccinated. </p>
<p>The health system needs to be there for everyone, not just people who look like us, nor just for people we like, nor just for people whose choices we endorse.</p>
<p>Nudges to encourage people to get vaccinated are good public policy. But if they undermine the universality of health care, these well-intentioned policies would cause more harm than good.</p>
<p><em>Correction: an earlier version of this article incorrectly said unvaccinated people in the ACT were subject to certain restrictions and ACT hospitals were under pressure.</em></p><img src="https://counter.theconversation.com/content/171669/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities, as disclosed on its website.</span></em></p>Singapore will start charging people who choose not to be vaccinated for any COVID-related hospital care. While Australia’s hospitals are also under pressure, we shouldn’t follow suit.Stephen Duckett, Director, Health and Aged Care Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1658052021-08-11T20:08:57Z2021-08-11T20:08:57ZHow does Australia’s health system rate internationally? This year it wins bronze<figure><img src="https://images.theconversation.com/files/415581/original/file-20210811-28-nfhsms.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/coronavirus-hospital-covid-19-woman-medical-1721906755">Shutterstock</a></span></figcaption></figure><p>In the wake of the Tokyo Olympics, another international scorecard has been released, and Australia does well here too.</p>
<p>The US-based <a href="https://www.commonwealthfund.org/">Commonwealth Fund</a> conducts regular surveys of health care in 11 countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States. </p>
<p>In its <a href="https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly">latest comparison</a>, Australia ranks third overall, slipping from second in the previous <a href="https://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-2017-international-comparison-reflects-flaws-and">comparison</a> in 2017. </p>
<p>The US, not unexpectedly, ranks last overall, and last on four of the five component rankings.</p>
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<img alt="" src="https://images.theconversation.com/files/415579/original/file-20210811-13-w0hgan.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/415579/original/file-20210811-13-w0hgan.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=493&fit=crop&dpr=1 600w, https://images.theconversation.com/files/415579/original/file-20210811-13-w0hgan.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=493&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/415579/original/file-20210811-13-w0hgan.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=493&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/415579/original/file-20210811-13-w0hgan.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=620&fit=crop&dpr=1 754w, https://images.theconversation.com/files/415579/original/file-20210811-13-w0hgan.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=620&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/415579/original/file-20210811-13-w0hgan.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=620&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Australia comes in at number 3 overall, after The Netherlands and Norway.</span>
<span class="attribution"><a class="source" href="https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly">Eric C. Schneider et al., Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries (Commonwealth Fund, Aug. 2021)</a></span>
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Read more:
<a href="https://theconversation.com/creating-a-better-health-system-lessons-from-the-netherlands-30270">Creating a better health system: lessons from the Netherlands</a>
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<h2>Why did Australia get bronze overall?</h2>
<p>Australia was awarded gold for two of the five component rankings: <em>equity</em> and <em>health care outcomes</em>.</p>
<p>The <em>equity</em> score is based on measures of disparity. For example, how different is access to care for people with above-average income compared to people with below-average income? </p>
<p>Australia’s Medicare scheme helps explain our good performance on this dimension.</p>
<p><em>Health care outcomes</em> incorporates measures such as life expectancy and infant mortality rates. </p>
<p>Australia scored well on these and on outcomes of health care, such as the rate of women dying in childbirth, or of people dying in the month after being discharged from hospital after a heart attack.</p>
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<img alt="Nurses in scrubs makes a hospital bed." src="https://images.theconversation.com/files/415583/original/file-20210811-27-1a5j7c5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/415583/original/file-20210811-27-1a5j7c5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/415583/original/file-20210811-27-1a5j7c5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/415583/original/file-20210811-27-1a5j7c5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/415583/original/file-20210811-27-1a5j7c5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/415583/original/file-20210811-27-1a5j7c5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/415583/original/file-20210811-27-1a5j7c5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Australia’s health system delivers good health outcomes for patients.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/nurse-making-bed-hospital-1222319512">Shutterstock</a></span>
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<p>Australia scored silver on <em>administrative efficiency</em>. Although primarily a measure of paperwork and its electronic equivalent, this also measures the ease with which medical practitioners can navigate the health system for their patients. </p>
<p>Australia’s good score again reflects well on Medicare as a single insurer. But it might also reflect Australia’s absence of a scheme requiring patients to get a second opinion from another doctor before surgery. <a href="https://link.springer.com/article/10.1007/s00432-015-2099-7">Second opinions can be useful</a>, so it might actually be disguising a shortcoming in the system.</p>
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Read more:
<a href="https://theconversation.com/explainer-what-is-medicare-and-how-does-it-work-22523">Explainer: what is Medicare and how does it work?</a>
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<h2>Now for the bad news</h2>
<p>Our overall score was dragged down by poor performance on the remaining two dimensions: <em>access to care</em> (where we were ranked 8th out of 11); and <em>care processes</em> (6th out of 11).</p>
<p>The first of these is not a surprise – stories about long waits for hospital care including <a href="https://www.abc.net.au/news/2021-07-26/call-for-hospital-surgery-waiting-list-fix-in-tasmania/100321714">elective procedures</a> and <a href="https://theconversation.com/getting-an-initial-specialists-appointment-is-the-hidden-waitlist-99507">outpatient appointments</a>, and <a href="https://theconversation.com/government-demands-for-arbitrary-performance-targets-are-contributing-to-ambulance-delays-paramedic-exhaustion-159823">ambulance ramping</a>, regularly feature in the media. </p>
<p><a href="https://grattan.edu.au/report/filling-the-gap/">Poor affordability of dental care</a> also contributed to Australia’s low score on <em>access to care</em>. </p>
<p>Australia performed somewhat better on access to primary care, which includes general practitioners.</p>
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<img alt="Child sits in a dentist's chair, holding a purple blanket to her chin." src="https://images.theconversation.com/files/415590/original/file-20210811-25-13cr1ls.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/415590/original/file-20210811-25-13cr1ls.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/415590/original/file-20210811-25-13cr1ls.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/415590/original/file-20210811-25-13cr1ls.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/415590/original/file-20210811-25-13cr1ls.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/415590/original/file-20210811-25-13cr1ls.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/415590/original/file-20210811-25-13cr1ls.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Dental care remains unaffordable for many in Australia.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-photo-asian-girl-dentist-wearing-1752063938">Shutterstock</a></span>
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<p>More than 30 separate indicators were used to judge <em>processes of care</em>, for which New Zealand was awarded gold. Here, Australia was judged in the middle of the pack, doing moderately well on preventive care, and moderately well on “patient engagement/preferences”, such as nurses and doctors always treating patients with respect.</p>
<p>But it was dragged down by measures of safe care, such as failure to have alert systems to provide pathology results back to patients, and high hospital infection rates.</p>
<p>Australia’s <em>processes of care</em> score was also brought down by poor care coordination. For example, GPs aren’t necessarily notified when their patient presents to an emergency department. And specialists’ reports on patients aren’t sent to GPs within a week of the patient’s visit.</p>
<h2>What do we need to improve? More funding</h2>
<p>Problems with access to health care will not be easy to fix. The federal government has limited growth in its funding to the states for hospital care to <a href="https://theconversation.com/public-hospital-blame-game-heres-how-we-got-into-this-funding-mess-89498">6.5% each year</a>. This does not keep pace with growth in demand.</p>
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Read more:
<a href="https://theconversation.com/public-hospital-blame-game-heres-how-we-got-into-this-funding-mess-89498">Public hospital blame game – here's how we got into this funding mess</a>
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<p>States can either find the additional money elsewhere to meet rising demand for health care (for example, by increasing state taxes such as payroll tax, or making cuts elsewhere). Or it can ration services, such as not providing enough operating theatre time (which results in longer waiting times for elective procedures). Or it can improve efficiency – and there is some scope for that in almost every state. States will typically do a mix of all three.</p>
<p>However, states alone can’t improve efficiency, because some measures fall within the federal government’s control. The federal government is responsible for primary care, for example, so it’s difficult for the states to design strategies to keep people out of hospital by making better use of primary care.</p>
<p>An easier option for states is to apply political pressure to get the federal government to lift the cap on funding and give the states more money. We can expect to see more of this in the lead up to the next federal election, which <a href="https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/rp1920/NextElection">will be held before mid-May 2022</a>.</p>
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<img alt="Specialist doctor at a desk talks to a patient, who sits facing her." src="https://images.theconversation.com/files/415592/original/file-20210811-20-y6bpp0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/415592/original/file-20210811-20-y6bpp0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/415592/original/file-20210811-20-y6bpp0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/415592/original/file-20210811-20-y6bpp0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/415592/original/file-20210811-20-y6bpp0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/415592/original/file-20210811-20-y6bpp0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/415592/original/file-20210811-20-y6bpp0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Communication is often lacking between GPs and specialists.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/smiling-female-doctor-facemask-white-uniform-1879853074">Shutterstock</a></span>
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<p>Improving <em>processes of care</em> will also be difficult, but hopefully improved electronic patient records in hospitals will facilitate quicker communication between hospitals and GPs.</p>
<h2>Why do these rankings matter?</h2>
<p>International comparisons help us identify opportunities to improve – but only if we avoid simply basking in a self-congratulatory glow from our high overall ranking. </p>
<p>The Commonwealth Fund survey is by no means perfect – there is some volatility in rankings of components from edition to edition – but it does allow us to drill down into the important attributes of health care, and to identify where others are doing better.</p>
<p>We should now set ourselves an agenda of what we want to learn and from whom.</p>
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<p>
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<strong>
Read more:
<a href="https://theconversation.com/medicare-needs-to-change-with-the-times-but-rushing-this-could-leave-patients-with-higher-gap-fees-162250">Medicare needs to change with the times, but rushing this could leave patients with higher gap fees</a>
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<img src="https://counter.theconversation.com/content/165805/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment from each of the Federal and Victorian Governments, BHP Billiton, and NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities as disclosed on its website.</span></em></p>Compared to ten similar countries, Australia does well on equity and health care outcomes. But it still has a way to go on access and how well the health system fits together.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1365952020-04-24T12:21:49Z2020-04-24T12:21:49ZPrice controls don’t work – but mask rationing is the exception that proves the rule<figure><img src="https://images.theconversation.com/files/330270/original/file-20200424-126804-17dyfpd.jpg?ixlib=rb-1.1.0&rect=102%2C51%2C2741%2C1944&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The shortage of masks could get worse.</span> <span class="attribution"><span class="source">Aleksandr Zubkov/Getty Images</span></span></figcaption></figure><p>The Centers for Disease Control and Prevention recommends that people wear a <a href="https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html">cloth face covering</a> for their nose and mouth to protect others from the spread of the coronavirus. Research shows masks lead to a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3591312/">more than threefold reduction</a> in how much flu virus people spray into the air. </p>
<p>Yet <a href="https://www.sciencenews.org/article/coronavirus-covid-19-ppe-face-mask-shortages-creative-solutions">there have</a> <a href="https://www.thecalifornian.com/story/news/2020/03/26/california-farmworkers-need-face-masks-but-cant-find-them-amid-covid-19-fear-coronavirus/4957564002/">been reports</a> for weeks that <a href="https://fox4kc.com/news/health/face-mask-shortages-affecting-midwest-construction-workers/">there are shortages</a> of <a href="https://www.nytimes.com/2020/03/25/opinion/coronavirus-face-mask.html">face masks</a>, both the <a href="https://www.vox.com/recode/2020/4/1/21196941/coronavirus-n95-mask-respirator-shortage-trump">N95 respirators</a> needed by health workers and the <a href="https://www.ft.com/content/f726a253-664f-406f-8daf-6b313c0cf8e4">simpler ones worn by the public</a>. While <a href="https://news.3m.com/blog/3m-stories/3m-responds-2019-novel-coronavirus">companies have promised</a> to ramp up supplies, those will likely be overwhelmed by demand as lockdowns ease and <a href="https://theconversation.com/hand-washing-and-distancing-dont-have-tangible-benefits-so-keeping-up-these-protective-behaviors-for-months-will-be-tricky-136457">more people need masks</a> as they return to public life.</p>
<p>Countries such as <a href="https://www.wsj.com/articles/south-korea-rations-face-masks-in-coronavirus-fight-11584283720">South Korea</a> and <a href="https://annals.org/aim/fullarticle/2764743/community-pharmacists-taiwan-frontline-against-novel-coronavirus-pandemic-gatekeepers-rationing">Taiwan</a> have responded to shortages by imposing price controls and rationing. </p>
<p>As an economist who wrote a textbook on <a href="https://books.google.com/books/about/Price_Theory_and_Applications.html?id=VbrKgDK-rioC">price theory</a> and teaches it to undergraduates, I’m generally skeptical about price controls. But not in this case.</p>
<h2>Why price controls are normally bad</h2>
<p>In economics, the price of a given product generally tends to <a href="https://www.khanacademy.org/economics-finance-domain/ap-macroeconomics/basic-economics-concepts-macro/market-equilibrium-disequilibrium-and-changes-in-equilibrium/a/lesson-summary-market-equilibrium-disequilibrium-and-changes-in-equilibrium">find its “equilibrium,”</a> where demand and supply are equal.</p>
<p>A shortage of a good typically results from a sudden drop in supply – for example, a factory gets hit by a hurricane – or because its price falls below this equilibrium. At this point, more people will want to buy the product than companies are willing to sell at that price. Normally, the reduced supply would cause the price to rise. But when there are price controls, the shortage remains. </p>
<p>For most goods, it is unwise to impose price controls because it causes companies to produce or provide less of the good, which forces some form of rationing, whether imposed by companies – for example, <a href="https://www.businessinsider.com/products-rationed-covid-19-panic-buying-novel-coronavirus-2020-3">limiting the number of rolls of toilet paper</a> a customer can buy – or government. </p>
<p>In either case, <a href="https://www.jstor.org/stable/2006510">people who value or may most need a good don’t get it</a>, while others with less need – or simply more money – can get a lot more and even hoard it. </p>
<p>There is a long history of governments implementing price controls and rationing.</p>
<p>Medieval governments <a href="http://www.doi.org/10.1111/j.1468-0289.2004.00285.x">fixed the maximum price of bread</a>. During World War II, the U.S. government allowed no driver to own more than <a href="https://www.history.com/this-day-in-history/office-of-price-administration-begins-to-ration-automobile-tires">five automobile tires</a> and let people <a href="https://www.saturdayeveningpost.com/2017/05/stomach-americas-wartime-sugar-ration-75-years-ago/">buy only half a pound of sugar</a> per week.</p>
<p>During the early 1970s, the <a href="https://www.instituteforenergyresearch.org/regulation/crazy-crude-oil-price-controls-1970s/">government set price controls</a> on gasoline leading up to the oil embargo of 1973 and ended up rationing who was able to fill up their tanks amid severe shortages. These <a href="https://history.state.gov/milestones/1969-1976/oil-embargo">price controls caused havoc</a> and <a href="https://www.manhattan-institute.org/howwegothere">violence</a>. Up to 20% of American gasoline stations sometimes had no fuel. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/330271/original/file-20200424-126813-10dvz4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/330271/original/file-20200424-126813-10dvz4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=461&fit=crop&dpr=1 600w, https://images.theconversation.com/files/330271/original/file-20200424-126813-10dvz4i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=461&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/330271/original/file-20200424-126813-10dvz4i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=461&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/330271/original/file-20200424-126813-10dvz4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=580&fit=crop&dpr=1 754w, https://images.theconversation.com/files/330271/original/file-20200424-126813-10dvz4i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=580&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/330271/original/file-20200424-126813-10dvz4i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=580&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The U.S. rationed sugar during World War II.</span>
<span class="attribution"><span class="source">AP Photo/Robert Kradin</span></span>
</figcaption>
</figure>
<h2>Why masks are different</h2>
<p>But masks, hand sanitizers and vaccinations are different from most goods because they may benefit more than just the person using them.</p>
<p>A face mask, for example, <a href="https://theconversation.com/why-wear-face-masks-in-public-heres-what-the-research-shows-135623">may help reduce</a> the chances that he or she will infect others nearby. Economists call this a “<a href="https://www.newyorker.com/news/our-columnists/the-nobel-committee-honors-the-economics-of-market-failure">positive externality</a>,” and it is the main reason the CDC began recommending people wear masks in public.</p>
<p>Since the people who may be infected from an uncovered sneeze or cough will often be total strangers, an individual may not fully take their health into account when deciding whether to buy and wear a mask. So when a product becomes scarce, pushing up prices, the problem is that a person willing to pay the higher price may not be someone whose use of a mask would most benefit others.</p>
<p>So let’s imagine two men. The first one can do his well-paid professional job from home and doesn’t go out because he fears getting the coronavirus. The other is an essential worker who must continue to do his low-income job everyday and interact with others in close proximity. When the <a href="https://www.nytimes.com/2020/04/03/technology/coronavirus-masks-shortage.html">price of masks shoots up</a>, the first man can easily afford to order a supply for himself via Amazon, but the other is unable to do so. </p>
<p>Since the first man interacts with few others, there’s little benefit to his wearing a mask. But the essential worker interacts with dozens of people daily, which means he’s protecting many others by wearing a mask. </p>
<p>In other words, allowing the market to ration a scarce good through higher prices means the wrong people are likely to get it. Moreover, <a href="https://nypost.com/2020/03/30/brooklyn-man-arrested-for-hoarding-masks-coughing-on-fbi-agents/">some people may end up hoarding masks</a>, whether for personal use or to sell at even higher prices.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/330272/original/file-20200424-126817-xpu7he.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/330272/original/file-20200424-126817-xpu7he.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=417&fit=crop&dpr=1 600w, https://images.theconversation.com/files/330272/original/file-20200424-126817-xpu7he.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=417&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/330272/original/file-20200424-126817-xpu7he.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=417&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/330272/original/file-20200424-126817-xpu7he.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=524&fit=crop&dpr=1 754w, https://images.theconversation.com/files/330272/original/file-20200424-126817-xpu7he.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=524&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/330272/original/file-20200424-126817-xpu7he.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=524&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Price controls can help ensure those who need them most, like medical workers in New York, have them.</span>
<span class="attribution"><span class="source">Noam Galai/Getty Images</span></span>
</figcaption>
</figure>
<h2>Markets sometimes need a little help</h2>
<p>Two of the countries <a href="https://foreignpolicy.com/2020/04/02/countries-succeeding-flattening-curve-coronavirus-testing-quarantine/">touted as coronavirus success stories</a> have been rationing masks. </p>
<p><a href="https://www.wsj.com/articles/south-korea-rations-face-masks-in-coronavirus-fight-11584283720">South Korea</a> limits the price to US$1.20 a mask, far below the previous market price of $2.00. And it imposes a weekly ration of two face masks per person. <a href="https://annals.org/aim/fullarticle/2764743/community-pharmacists-taiwan-frontline-against-novel-coronavirus-pandemic-gatekeepers-rationing">Taiwan’s government</a> rationed masks to prevent panic buying and prioritize allocations to health personnel. At the same time, production was ramped up so that individuals are allowed 10 masks every two weeks. </p>
<p>The U.S. could do something similar. For example, the government could buy a large share of the available masks and distribute them at a low price to families in places with high infection rates – in effect a price control. Or, if Americans prefer to avoid direct governmental distribution, the federal government could set the price and require that no more than two masks be sold per person.</p>
<p>This doesn’t mean that all medical supplies should be under price control or rationed. But price controls on goods like masks, hand sanitizer or vaccines, once they become available, can be useful if doing so helps limit the spread of the coronavirus.</p>
<p>The market generally works. But sometimes it needs an assist.</p>
<p>[<em>Insight, in your inbox each day.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=insight">You can get it with The Conversation’s email newsletter</a>.]</p><img src="https://counter.theconversation.com/content/136595/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The Program in Corporate Welfare at UC Irvine, which Amihai Glazer directs, receives funding from the Charles Koch Foundation and the Troesh Family Foundation.</span></em></p>Shortages of face masks may grow worse as state-wide lockdowns end. An economist suggests price controls.Amihai Glazer, Professor of Economics, University of California, IrvineLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1352142020-04-01T05:12:22Z2020-04-01T05:12:22ZIf coronavirus cases don’t grow any faster, our health system will probably cope<p>The growth in COVID-19 cases in Australia appears to have slowed across all states, through a combination of tighter border control and spatial distancing.</p>
<p>With the number of new cases each day growing at a slower rate, there is a chance the pandemic can be brought under control and dealt with in our existing public hospital system – even without <a href="https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/australian-government-partnership-with-private-health-sector-secures-30000-hospital-beds-and-105000-nurses-and-staff-to-help-fight-covid-19-pandemic">help from the private system</a>. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/federal-government-gets-private-hospital-resources-for-covid-19-fight-in-exchange-for-funding-support-135207">Federal government gets private hospital resources for COVID-19 fight in exchange for funding support</a>
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</em>
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<hr>
<p>However, it’s still too early to say for sure. Although Australia is testing more people than many other countries, it is only just starting to relax its criteria and testing more people with COVID-19-like symptoms. </p>
<p>As testing expands, we’ll have a better idea of how the health system will cope. But here’s what we know so far.</p>
<h2>Australia’s infection rate appears to be slowing</h2>
<p>The number of new COVID-19 cases in Australia has flattened over the past five days. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/324445/original/file-20200331-66148-zgrfij.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/324445/original/file-20200331-66148-zgrfij.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/324445/original/file-20200331-66148-zgrfij.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/324445/original/file-20200331-66148-zgrfij.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/324445/original/file-20200331-66148-zgrfij.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/324445/original/file-20200331-66148-zgrfij.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/324445/original/file-20200331-66148-zgrfij.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"></span>
</figcaption>
</figure>
<p>This is not just because new arrivals have slowed with much tighter border controls, and the slump in international air travel. The number of new <em>local</em> infections each day is also not growing.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/324444/original/file-20200331-66130-1sz0gwh.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/324444/original/file-20200331-66130-1sz0gwh.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/324444/original/file-20200331-66130-1sz0gwh.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/324444/original/file-20200331-66130-1sz0gwh.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/324444/original/file-20200331-66130-1sz0gwh.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/324444/original/file-20200331-66130-1sz0gwh.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/324444/original/file-20200331-66130-1sz0gwh.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/324444/original/file-20200331-66130-1sz0gwh.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"></a>
<figcaption>
<span class="caption"></span>
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<p>For most of March, the total number of cases doubled in Australia every <a href="https://blog.grattan.edu.au/2020/03/australias-covid-19-are-still-growing-rapidly-our-hospitals-may-soon-hit-capacity/">three to four days</a>. That rate has now slowed to doubling every six to seven days. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/324446/original/file-20200331-66125-1sby8ax.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/324446/original/file-20200331-66125-1sby8ax.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/324446/original/file-20200331-66125-1sby8ax.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/324446/original/file-20200331-66125-1sby8ax.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/324446/original/file-20200331-66125-1sby8ax.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/324446/original/file-20200331-66125-1sby8ax.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/324446/original/file-20200331-66125-1sby8ax.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"></span>
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<p>The chart below shows this slowing occurred in each state that has a significant number of COVID-19 cases, and consistently from March 20.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/324447/original/file-20200331-66125-xml9h1.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/324447/original/file-20200331-66125-xml9h1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/324447/original/file-20200331-66125-xml9h1.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/324447/original/file-20200331-66125-xml9h1.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/324447/original/file-20200331-66125-xml9h1.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/324447/original/file-20200331-66125-xml9h1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/324447/original/file-20200331-66125-xml9h1.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/324447/original/file-20200331-66125-xml9h1.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"></a>
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<span class="caption"></span>
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<p>On March 16, gatherings of more than 500 people were banned and all international arrivals <a href="https://www.canberratimes.com.au/story/6679875/travellers-return-from-abroad-grappling-with-new-self-isolation-restrictions/">were required to self-isolate</a> for 14 days. </p>
<h2>The health system will probably cope</h2>
<p>Slowing the growth of new cases will ease pressure on the hospital system. </p>
<p>If we continued to double the number of cases every three to four days, we would have hit the then-capacity of intensive care units (ICUs) of about 2,200 beds <a href="https://blog.grattan.edu.au/2020/03/as-more-australians-get-covid-19-will-we-have-enough-hospital-beds/">in about mid-April when the number of new cases hit 12,000 per day</a>. Doubling or even tripling the number of ICU beds would have delayed the crunch by a week.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/what-steps-hospitals-can-take-if-coronavirus-leads-to-a-shortage-of-beds-134385">What steps hospitals can take if coronavirus leads to a shortage of beds</a>
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<p>At the current doubling rate, of six to seven days, that crunch would hit in early May. </p>
<p>But the doubling rate is falling and so that crunch time will probably be pushed out even further.</p>
<p>The slower COVID-19 spreads, the more time we get to prepare health systems and increase the capacity of ICUs, where necessary. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/324448/original/file-20200331-66125-kumvo4.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/324448/original/file-20200331-66125-kumvo4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/324448/original/file-20200331-66125-kumvo4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/324448/original/file-20200331-66125-kumvo4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/324448/original/file-20200331-66125-kumvo4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/324448/original/file-20200331-66125-kumvo4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/324448/original/file-20200331-66125-kumvo4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/324448/original/file-20200331-66125-kumvo4.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"></a>
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<p>Over the past week the growth pattern has slowed and shifted from the exponential doubling to a linear trend with the number of new cases in Australia increasing by about 350 per day. If this rate continues, Australia’s current ICU capacity will be able to cope.</p>
<p>But it is still early days. And our current testing regime may not be shedding as much light on community transmission as we need. With limited community testing, and a disease which is asymptomatic or mild for many, we don’t know how far infections have spread into the community and so we don’t know the actual number of new cases each day. </p>
<h2>But we need to test more broadly to understand the spread</h2>
<p>With <a href="https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-19-current-situation-and-case-numbers">more than 250,000 COVID-19 tests so far</a>, Australia has a high testing rate compared to <a href="https://ourworldindata.org/covid-testing">other countries</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/324449/original/file-20200331-66109-msmutq.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/324449/original/file-20200331-66109-msmutq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/324449/original/file-20200331-66109-msmutq.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/324449/original/file-20200331-66109-msmutq.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/324449/original/file-20200331-66109-msmutq.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/324449/original/file-20200331-66109-msmutq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/324449/original/file-20200331-66109-msmutq.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/324449/original/file-20200331-66109-msmutq.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"></a>
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<p>But the number of testing kits has been limited, so Australia has done “targeted” rather than “widespread” testing. </p>
<p><a href="https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/what-you-need-to-know-about-coronavirus-covid-19#testing">The Commonwealth government</a> previously advised doctors to limit testing to people who develop a respiratory illness and have either returned from overseas or been in close contact with a confirmed COVID-19 case in the past fortnight.</p>
<p>As the <a href="https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-19-advice-for-travellers#travel-to-australia">restrictions on international arrivals</a> kick in, community transmission will become the main source of COVID-19 risk.</p>
<p>The Commonwealth government last week <a href="https://www.pm.gov.au/media/national-cabinet-update">expanded the testing criteria</a> to people who have fever or acute respiratory infection and are in an at-risk group (for example, a health worker) or setting (such as a geographic area with confirmed clusters of cases).</p>
<p>Some states have gone further. <a href="https://www.health.nsw.gov.au/Infectious/diseases/Pages/coronavirus-update.aspx">New South Wales</a> now allows GPs to refer for testing people with COVID-19 symptoms. </p>
<p>Victoria has introduced <a href="https://www.abc.net.au/news/2020-03-27/coronavirus-testing-stepped-up-in-regional-victoria/12095632">randomised testing</a> at its screening centres to get a better understanding of how the virus is spreading. This involves testing every fifth person who presents at the clinic, in addition to those who meet the testing criteria. </p>
<p>As overseas cases fall and our testing capability rises, all states should implement some form of randomised testing in the community.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/to-get-on-top-of-the-coronavirus-we-also-need-to-test-people-without-symptoms-134381">To get on top of the coronavirus, we also need to test people without symptoms</a>
</strong>
</em>
</p>
<hr>
<p>As the testing criteria is further relaxed and picks up more cases of community transmission, we will get a better understanding of how the virus is spreading in the community. Only then can we be confident about the adequacy of our health system in the coming months.</p><img src="https://counter.theconversation.com/content/135214/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>Anika Stobart and Will Mackey 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>Over the past week, we’ve seen about 350 new cases per day. If this rate continues, Australia’s current ICU system will be able to cope.Stephen Duckett, Director, Health Program, Grattan InstituteAnika Stobart, Associate, Grattan InstituteWill Mackey, Associate, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1343832020-03-26T02:38:24Z2020-03-26T02:38:24ZPeople with a disability are more likely to die from coronavirus – but we can reduce this risk<figure><img src="https://images.theconversation.com/files/323087/original/file-20200325-168912-2rp3q8.jpg?ixlib=rb-1.1.0&rect=48%2C20%2C4565%2C3272&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/paralyzed-man-praying-on-his-wheelchair-597692201">Shutterstock</a></span></figcaption></figure><p>The COVID-19 pandemic is terrifying for many of us, but people with a disability have more reason to worry than most. </p>
<p>People with a disability often have <a href="https://www.who.int/news-room/fact-sheets/detail/disability-and-health">underlying health conditions</a> that make them more susceptible to serious illness or death if they contract COVID-19. They may also be more at risk of contracting the virus if they have disability workers entering their home. </p>
<p>The federal government has made several policy announcements to protect older Australians in aged care facilities, hospitals and GP clinics, but we’re yet to see the same consideration for people with disabilities. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/private-hospitals-get-grace-period-before-freeze-on-non-urgent-elective-surgery-134684">Private hospitals get grace period before freeze on non-urgent elective surgery</a>
</strong>
</em>
</p>
<hr>
<h2>People with disability are already disadvantaged</h2>
<p><a href="https://www.and.org.au/pages/disability-statistics.html">One in five people</a> in Australia has a disability. Of these, more than three-quarters report a physical disability, although many report multiple types.</p>
<p>People with disabilities are at higher risk of serious illness and death from coronavirus death due to <a href="https://www.who.int/news-room/fact-sheets/detail/disability-and-health">higher rates of co-exisiting health conditions</a> such as diabetes, asthma and <a href="https://theconversation.com/explainer-what-is-chronic-obstructive-pulmonary-disease-25539">chronic pulmonary obstructive disease</a>:</p>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/320981/original/file-20200317-60906-11kmy5p.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/320981/original/file-20200317-60906-11kmy5p.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/320981/original/file-20200317-60906-11kmy5p.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=341&fit=crop&dpr=1 600w, https://images.theconversation.com/files/320981/original/file-20200317-60906-11kmy5p.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=341&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/320981/original/file-20200317-60906-11kmy5p.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=341&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/320981/original/file-20200317-60906-11kmy5p.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=429&fit=crop&dpr=1 754w, https://images.theconversation.com/files/320981/original/file-20200317-60906-11kmy5p.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=429&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/320981/original/file-20200317-60906-11kmy5p.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=429&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>People with disability are more likely to be <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/9781118924396.wbiea2316">poorer, not working and more socially isolated</a>. This makes them more vulnerable to poor health outcomes during the pandemic. </p>
<p>Evidence for previous pandemics shows that <a href="https://www.liebertpub.com/doi/10.1089/bsp.2014.0032">health inequities worsen during epidemics</a> as more marginalised communities have fewer resources (financial and social) and struggle to access necessary supplies and services. </p>
<p>On top of this, health information is rarely presented in an accessible format for children and adults with intellectual disabilities, such as Easy English (a style of writing that’s simple and concise) and/or pictorial formats. </p>
<h2>People with disabilities must not be de-prioritised</h2>
<p>At a time when there is unprecedented demand for health services, we need to ensure people with disability don’t miss out. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-well-avoid-australias-hospitals-being-crippled-by-coronavirus-133920">How we'll avoid Australia's hospitals being crippled by coronavirus</a>
</strong>
</em>
</p>
<hr>
<p>Health services can be <a href="https://www.aihw.gov.au/reports/disability/access-health-services-disability/contents/content">inadequate</a> for people with disability at the best of times because of barriers such as physical inaccessibility, lack of understanding of a person’s disability, and cost. </p>
<p>We’ve already seen reports around the world that older people and those with disability have been de-prioritised in health services. </p>
<p>In Italy, the professional organisation that sets <a href="http://www.siaarti.it/SiteAssets/News/COVID19%20-%20documenti%20SIAARTI/SIAARTI%20-%20Covid19%20-%20Raccomandazioni%20di%20etica%20clinica.pdf">guidelines</a> for intensive care has stated health resources should prioritise those with the <a href="https://www.theatlantic.com/ideas/archive/2020/03/who-gets-hospital-bed/607807/">highest chance</a> of “therapeutic success”. </p>
<p>If people with disability have pre-existing health conditions, or if their particular impairment means their chance of recovery is diminished, they may be de-prioritised for intensive care. </p>
<p>Last week the Australia and New Zealand Intensive Care Society <a href="https://www.anzics.com.au/wp-content/uploads/2020/03/ANZICS-COVID-19-Guidelines-Version-1.pdf">updated its guidelines</a> for doctors, acknowledging that when the coronavirus pandemic peaks, difficult decisions may need to be made. </p>
<p>It recommends doctors make decisions based on the probable outcome, whether people have underlying health conditions, and the “burden of treatment” for the patient and their family. </p>
<p>The guidelines don’t mention people with disabilities, but it’s easy to see how an assessment of the “burden of treatment” could include people with intellectual disability becoming upset by treatment, or taking more time to deliver. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-coronavirus-pandemic-is-forcing-us-to-ask-some-very-hard-questions-but-are-we-ready-for-the-answers-132581">The coronavirus pandemic is forcing us to ask some very hard questions. But are we ready for the answers?</a>
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</em>
</p>
<hr>
<h2>Access to protective equipment and support</h2>
<p>For people who require support with activities of daily living (dressing, bathing, meal preparation, and so on) it’s likely they have one or possibly several care workers who will move in and out of their home every day. </p>
<p>Currently, many workers don’t have access to <a href="https://www.theguardian.com/world/2020/mar/17/australians-with-disabilities-missing-out-on-essential-services-as-covid-19-crisis-escalates">protective equipment</a>, such as <a href="https://www.abc.net.au/news/2020-03-20/disability-sector-particularly-at-risk-of-coronavirus-impact/12068090">gloves and masks</a>. </p>
<p>Disability care workers’ movement across multiple homes makes it likely that some of them will acquire and transmit COVID-19 to the people they care for.</p>
<p>Many of those working in care roles are among some of the <a href="https://theconversation.com/disability-workers-are-facing-longer-days-with-less-pay-93953">lowest paid</a> in our society and many are employed on a <a href="https://theconversation.com/new-risks-for-disability-care-workers-under-the-ndis-63812">casual basis</a>. If they don’t work a shift, they will not be paid. </p>
<p>This means we might be incentivising people who desperately need income to take risks with their health and the health of the people they’re supporting.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/323101/original/file-20200326-168894-ozi2fi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/323101/original/file-20200326-168894-ozi2fi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/323101/original/file-20200326-168894-ozi2fi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/323101/original/file-20200326-168894-ozi2fi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/323101/original/file-20200326-168894-ozi2fi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/323101/original/file-20200326-168894-ozi2fi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/323101/original/file-20200326-168894-ozi2fi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Many people with disabilities don’t have the option of self-isolating.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/two-friends-disability-rehabilitation-center-watching-531537415">Shutterstock</a></span>
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<p>Some providers are choosing to <a href="https://www.theguardian.com/world/2020/mar/17/australians-with-disabilities-missing-out-on-essential-services-as-covid-19-crisis-escalates">cancel shifts</a> and not put their staff at risk. This is one way to protect staff, but will leave some people with a disability in real need. </p>
<p>Even before this pandemic there were disability workforce <a href="https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/BriefingBook44p/CaringWorkforce">shortages</a>. This is likely to increase as the number of infections rises. </p>
<h2>What should we do?</h2>
<p>The <a href="https://credh.org.au/news-events/disability-and-health-sectors-need-a-coordinated-response-during-covid-19/">following actions</a> are urgently needed to protect people with a disability as the pandemic progresses:</p>
<ul>
<li><p>the establishment of an expert committee with members who have expertise in the disability and health sectors to advise government </p></li>
<li><p>a new MBS item to develop COVID-19 health care plans with children and adults with complex disabilities, so they know how to implement social distancing and hygiene measures, and how to access tests and treatment</p></li>
<li><p>a dedicated coronavirus information hotline for people with disabilities, families and disability services, staffed by people with deep understanding of disability issues and underlying health issues</p></li>
<li><p>significant supplies of personal protective equipment (such as masks, gloves and gowns) for the disability support workforce to reduce transmission</p></li>
<li><p>government guarantees of income for care workers who may be sick, have caring responsibilities or have their shifts cancelled</p></li>
<li><p>the mobilisation of a broader disability workforce, for example by drawing on allied health students.</p></li>
</ul>
<p>These actions won’t address all the inequities people with disabilities face, but they will be a good start.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-will-devastate-aboriginal-communities-if-we-dont-act-now-133766">Coronavirus will devastate Aboriginal communities if we don't act now</a>
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<img src="https://counter.theconversation.com/content/134383/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Helen Dickinson receives funding from the Australian Research Council The National Health and Medical Research Council and the Victorian and Commonwealth governments. </span></em></p><p class="fine-print"><em><span>Anne Kavanagh receives funding from the Australian Research Council, the National Health and Medical Research Council and the Victorian and Commonwealth governments.</span></em></p>The government has made several announcements to safeguard aged care residents and those in hospitals, but we’re yet to see the same attention paid to the one in five Australians with a disability.Helen Dickinson, Professor, Public Service Research, UNSW SydneyAnne Kavanagh, Professor of Disability and Health, Melbourne School of Population and Global Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1168142019-05-28T19:47:31Z2019-05-28T19:47:31ZSurgery rates are rising in over-85s but the decision to operate isn’t always easy<figure><img src="https://images.theconversation.com/files/276679/original/file-20190528-193518-nwxvjs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The decision about whether to operate can't just be based on age, though age-related decline is certainly a consideration. </span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/Y5VBtBgswLQ">Philippe Leone</a></span></figcaption></figure><p>In January, <a href="https://www.sbs.com.au/news/hip-replacement-for-107-year-old-a-success">107-year-old Daphne Keith</a> broke her hip and became the oldest Australian to have a partial hip replacement. This isn’t something you would have heard of two or three decades ago. </p>
<p>For Daphne, the decision was fairly clear-cut. Surgery, with all its risks, was a better option than the alternative: to be stuck in bed for the rest of her life. As she summed it up, “What do I have to lose?” </p>
<p>But in many cases the balance between benefits and harms of surgery for older people is not as clear-cut.</p>
<p>Advances in anaesthetic and surgical techniques (especially keyhole surgery) now allow older adults to undergo operations and procedures that were previously not possible.</p>
<p>As the population <a href="https://www.who.int/news-room/fact-sheets/detail/ageing-and-health">ages</a>, we’re operating on older and <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1002/bjs.11148">older people</a>. <a href="https://www.aihw.gov.au/getmedia/0b26353f-94fb-4349-b950-7948ace76960/ah16-6-17-health-care-use-older-australians.pdf.aspx">Rates for elective surgery</a> in Australia are increasing the most among those aged over 85.</p>
<p>So how do we decide who should and shouldn’t undergo surgery?</p>
<h2>Age is a factor, but not the only one</h2>
<p>As we age there are increasing differences between individuals in terms of how our minds and bodies function. Younger people – whether they’re aged five, 20 or even 40 – are generally very similar to their age-matched peers, in terms of their cognitive and physical abilities. </p>
<p>But if we compare older adults, there are marked differences in their function. Some 70-year-olds are fit, healthy and still working full-time. Other 70-year-olds have multiple medical conditions, are frail and living in nursing homes. </p>
<p>So decisions about surgery shouldn’t be based on age alone. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/whats-happening-in-our-bodies-as-we-age-67931">What's happening in our bodies as we age?</a>
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</em>
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<p>However, we can’t ignore the changes associated with ageing, which means sometimes the potential harms of surgery will outweigh the benefits.</p>
<p>The harms associated with surgery and anaesthesia include death, surgical complications, longer hospital stays and poorer long-term outcomes. This might mean not being able to return to the same physical or cognitive level of function or needing to go into a nursing home. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/276682/original/file-20190528-193514-y3mgrq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/276682/original/file-20190528-193514-y3mgrq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/276682/original/file-20190528-193514-y3mgrq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/276682/original/file-20190528-193514-y3mgrq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/276682/original/file-20190528-193514-y3mgrq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/276682/original/file-20190528-193514-y3mgrq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/276682/original/file-20190528-193514-y3mgrq.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">Two 70-year-olds can be in very different health and have vastly different preferences for what they want out of their health care.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1020771727?src=ECccqepuMQx8KTk8mGnOFA-1-89&size=huge_jpg">Rawpixel.com/Shutterstock</a></span>
</figcaption>
</figure>
<p>The changes in our body as we age, as well as an increase in the number of diseases, and therefore medications we take, can increase the risks associated with surgery and anaesthesia. </p>
<p>Frailty is the strongest predictor of poor outcomes after surgery. Frailty is a decrease in our body’s reserves and our ability to recover from stressful events such as surgery. Frailty is usually associated with increasing age, but not all older people are frail, and you can be frail and still relatively young. </p>
<h2>Consider the patient’s preferences</h2>
<p>Patients <a href="https://www.ncbi.nlm.nih.gov/pubmed/25531451">tend to overestimate the benefits</a> of surgery and underestimate the harms. This highlights the importance of shared decision-making between patients and clinicians.</p>
<p><a href="https://jamanetwork.com/journals/jama/article-abstract/1910118">Shared decision-making</a> means the patient and clinicians come to a decision together, after discussing the options, benefits and harms, and after considering the patient’s values, preferences and circumstances. </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>
</strong>
</em>
</p>
<hr>
<p>Research shows that <a href="https://www.nejm.org/doi/full/10.1056/NEJMsa012528">as we age</a> many of us become less focused on longevity and prolonging life at all costs and much more focused on what that life is like, or our quality of life. </p>
<p>Outcomes such as living independently, staying in our own home, the ability to move around, and being mentally alert often become increasingly important in the decision-making process. This information about a person’s values is critical for shared decision-making conversations.</p>
<p>When considering these preferences, the discussion becomes more than just “could” we do this operation – it’s about “should” we do this operation? Someone living at home with early dementia may decide the risk of this worsening, and the possible need to move to a nursing home, is not worth any benefits of surgery.</p>
<p>It’s also important to note that, in some cases, cognitive impairment and dementia associated with ageing mean it’s not the patient (but <a href="https://www.publicadvocate.vic.gov.au/medical-consent">their appointee</a>) making decisions about surgery.</p>
<h2>Not everyone should be offered surgery</h2>
<p>The ageing of our population raises challenges for policymakers. More surgeries means greater pressure on the health budget. We don’t have a bottomless pit of health funding, so how do we decide who is eligible, based on fair and equitable resource allocation?</p>
<p>Given the marked variability between individuals as we age, decisions and policies about access to medical care (including surgery) should not be based on age alone. There should not be policies that say “no” to surgery based on age. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/276684/original/file-20190528-193540-s5cf6p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/276684/original/file-20190528-193540-s5cf6p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/276684/original/file-20190528-193540-s5cf6p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/276684/original/file-20190528-193540-s5cf6p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/276684/original/file-20190528-193540-s5cf6p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/276684/original/file-20190528-193540-s5cf6p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/276684/original/file-20190528-193540-s5cf6p.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">More surgery means greater expenditure.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1023401932?src=6ueJ6xpFUHjwAWifoJ9AqA-1-33&size=huge_jpg">MAD.vertise/Shutterstock</a></span>
</figcaption>
</figure>
<p>Equally, when considering resource allocation, it should not just be about how many years a person has to live, or blunt assessments based on how much their operation might cost the health system.</p>
<p>Take a decision about performing a hip replacement on a 90-year-old with arthritis, for example. A patient who has an elective hip replacement for arthritis and is able to remain living at home will probably “cost less” overall than if that same person would otherwise have had to live in a nursing home.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/who-gets-a-piece-of-the-pie-spending-the-health-budget-fairly-13997">Who gets a piece of the pie? Spending the health budget fairly</a>
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</em>
</p>
<hr>
<p>However, this also does not mean we can, or should, offer surgery to everyone. </p>
<p>The practice of medicine, especially when considering older adults, needs to remain focused on individualised patient care. Decisions should be based on medical appropriateness of treatment combined with a patient’s goals and values.</p>
<p>To do this we need to train clinicians in shared decision-making and how to have these often difficult discussions. The goal is to have clinicians who are able to explore a patient’s values and preferences around outcomes, effectively communicate individualised information about options, benefits and harms, and then come to a decision together.</p><img src="https://counter.theconversation.com/content/116814/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claire McKie 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>Rates of elective surgery are rising most among those aged over 85, due to advances in anaesthesia and techniques such as keyhole surgery. But it’s also much riskier.Claire McKie, Senior Lecturer, Clinical and Communication Skills, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/596612016-05-20T02:01:17Z2016-05-20T02:01:17ZConfused about the Medicare rebate freeze? Here’s what you need to know<p>The Australian Labor Party <a href="http://www.abc.net.au/news/2016-05-19/labor-to-unveil-$12b-medicare-rebate-freeze-rollback/7426958">announced</a> yesterday that it will lift the Medicare rebate freeze if elected to office in the July federal election. We know health issues feature strongly in <a href="http://www.abc.net.au/news/2016-05-13/election-2016-policy-big-issues/7387588">election debates</a>, but what does this proposal actually mean for most of us? </p>
<h2>How Medicare works</h2>
<p>Medicare is our public health insurance system and funds a range of services such GP visits, blood tests, x-rays and consultations with other medical specialists. </p>
<p>The <a href="http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Home">Medicare Benefits Schedule</a> (MBS) lists the services the Australian government will provide a Medicare rebate for. Medicare rebates do not cover the full cost of medical services and are typically paid as a percentage of the Medicare schedule fee. </p>
<p>GPs who bulk bill agree to charge the Medicare schedule fee and are directly reimbursed by government. </p>
<p>Those who don’t bulk bill are free to set their own prices for services. Patients pay for their treatment and receive a rebate from Medicare. There is often a gap between what patients pay for services and the amount that Medicare reimburses (A$37 for a GP consultation, for example). This gap is known as an out-of-pocket expense, as the patient is required to make up the difference out of his or her own pocket. </p>
<p>Under an indexing process, the Medicare Benefits Schedule fees are raised according to the Department of Finance’s <a href="http://www.healthandlife.com.au/wp-content/uploads/2015/10/Out-in-the-cold_-MBS-freeze-hits-today.pdf">Wage Cost Index</a>, a combination of indices relating to wage levels and the <a href="http://www.treasury.nt.gov.au/Economy/EconomicBriefs/Pages/ConsumerPriceIndex.aspx">Consumer Price Index</a>. </p>
<p>Organisations such as the Australian Medical Association (AMA) have long argued this process is insufficient and Medicare schedule fees have not kept up with <a href="https://ama.com.au/system/tdf/documents/Guide%20for%20Patients%20on%20How%20the%20Health%20Care%20System%20Funds%20Medical%20Care_7.pdf?file=1&type=node&id=40914">“real”</a> increases in costs to medical practitioners of delivering services. The rebate freeze compounds this financial challenge by continuing to keep prices at what the AMA and others argue are <a href="https://ama.com.au/system/tdf/documents/Guide%20for%20Patients%20on%20How%20the%20Health%20Care%20System%20Funds%20Medical%20Care_7.pdf?file=1&type=node&id=40914">“unsustainable levels”</a>. </p>
<h2>Where did the freeze come from?</h2>
<p>Although the Coalition is largely associated with this issue, Labor first introduced the Medicare rebate freeze in 2013 as a “temporary” measure, as part of a A$664 million budget savings plan. The AMA, the Coalition and others <a href="http://www.abc.net.au/news/2013-10-16/medicare-rebate-freeze-row-as-patients-face-increasing-costs/5026996">loudly criticised</a> the then government for the freeze. </p>
<p>On being elected to office, the Coalition put forward a number of proposals to reform the payment of health services and deal with rapidly rising health costs. Health expenditure had grown <a href="https://theconversation.com/tough-choices-how-to-rein-in-australias-rising-health-bill-13658">74% over the past decade</a> and was considered unsustainable in the long term. Primary care and medical services costs (including Medicare) had grown by more than 60%, representing an <a href="https://theconversation.com/tough-choices-how-to-rein-in-australias-rising-health-bill-13658">A$11 billion increase</a>.</p>
<p>The Coalition government proposed a number of ill-fated reforms including: </p>
<ul>
<li>a A$7 co-payment for GP, pathology and imaging services that would offset a A$5 reduction in Medicare rebates</li>
<li>a ten-minute minimum for standard GP consultations</li>
<li>a A$5 reduction in the Medicare rebate for “common GP consultations”.<br></li>
</ul>
<p>The retraction of all these proposals led Prime Minister Tony Abbott to declare co-payments <a href="http://www.abc.net.au/news/2015-03-03/tony-abbott-declares-gp-co-payment-dead,-buried-and-cremated/6275912">“dead, buried and cremated”</a>.</p>
<p>What did manage to stick was a continuation of the indexation freeze, initially for four years starting in July 2014 and further extended in the <a href="https://theconversation.com/federal-budget-2016-health-experts-react-58638">recent federal budget</a> to 2020. It has been estimated this will save <a href="https://ama.com.au/nomedicarefreeze">A$2.8 billion</a> from the health bill over the six years. </p>
<h2>Impact of the freeze</h2>
<p>The extended freeze means GPs and other medical specialists will be reimbursed the same amount for delivering health services in 2020 as they were in 2014. Doctors will pay more for their practices, staff, medical products, utilities and just about anything else that goes into running a medical practice. But the amount paid for medical services will remain static.</p>
<p>At the time the Coalition extended the freeze in 2014, <a href="https://theconversation.com/high-cost-of-gp-rebate-freeze-may-see-co-payments-rise-from-the-dead-38786">research</a> showed this move would have a greater impact on GP income over the initial four-year freeze than the proposed $A5 reduction in the GP rebate would have produced. In other words, failing to lift the reimbursement amount would ultimately prove more detrimental to GP funding than actually reducing the rebate amount. </p>
<p>Opponents to these changes argue this leaves medical services underfunded and may ultimately mean that additional payments will be passed on to patients. AMA president Brian Owler estimates the extended freeze will lead to each GP visit costing <a href="https://theconversation.com/shorten-government-would-end-freeze-on-medicare-rebates-59655">A$20 more</a> for patients. Some commentators referred to this as the introduction of the co-payment by the <a>“back door”</a>. </p>
<p>Some argued it could reduce the number of bulk-billing practices. Yet levels have risen steadily since 2013 to an all-time high of <a href="http://www.australiandoctor.com.au/news/news-review/why-are-gps-still-bulk-billing-at-record-levels">84.3%</a>. </p>
<p>What about costs passed on to patients? The AMA estimates suggest that at present the Medicare rebate (A$37) covers only about 50% of the <a href="http://www.afr.com/news/politics/election/federal-election-2016-bill-shorten-attacks-medicare-freeze-as-backdoor-tax-20160515-govfi2">recommended consulting fee</a>. This means that either medical practitioners cover the remainder of the costs themselves or pass this on to patients.</p>
<p>The impact of the extended freeze goes beyond simply reducing the gross income of GPs, or patients having to pay more for their health services. There are profound implications for equity. The effects of these types of policies are typically regressive in that the impact is often greatest on the <a>most disadvantaged</a> within our community. </p>
<p>Australia already has a large gap between the quality and timeliness of the public and private health systems. Changes such as this could potentially exacerbate this gap, by reducing the number of bulk-billing practices. This has the potential to create a two-tier system, where those who can pay receive the best care and those who can’t pay delay or avoid treatment, which ultimately exacerbates their condition. </p>
<p>The Coalition expects GPs and medical professionals to pass on costs to the patient, thereby sending <a href="https://theconversation.com/gp-co-payments-why-price-signals-for-health-dont-work-28857">“price signals”</a> about health services, with the aim of reducing the numbers of “unnecessary” consultations. However, the international evidence shows that increased co-payments for patients may <a href="https://www.mja.com.au/journal/2014/200/7/copayments-general-practice-visits">save a little money</a> in the short term, but can ultimately increase <a href="http://www.abc.net.au/am/content/2016/s4465085.htm">the number of people accessing hospitals</a> and other acute services, which are more expensive to run. </p>
<h2>Labor’s bid to end the freeze</h2>
<p>Labor’s announcement that it will end the freeze and restore indexation from January 1, 2017, has been costed at A$2.4 billion by 2019-20 and A$12.2 billion over a decade. </p>
<p>The AMA and other medical professional groups that have argued against these measures have welcomed this announcement. And Labor will no doubt be pleased to have such powerful interest groups on side (for now at least). But critics will ask where this money will be found in the budget and what will need to give in return. </p>
<p>Ultimately, just unfreezing the Medicare rebate will not make Australian health services more sustainable in the long term. There is an urgent need to reconsider how we incentivise and reimburse medical practitioners for the services they deliver and how we invest in preventive measures to avoid people becoming sick in the first place. </p>
<p>At a time when we see significant increases in levels of chronic and complex diseases, we need a health system that is designed to serve these issues and not simply episodic periods of illness. Without a broader mandate for change within the health system it is unlikely that this promise alone will lead to better health services for all of our community.</p><img src="https://counter.theconversation.com/content/59661/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Helen Dickinson receives funding from Federal Department of Health </span></em></p>Labor will lift the rebate freeze from 2017, while under the Coalition, GPs will be paid the same amount for delivering health services in 2020 as they were in 2014. So what does this mean for patients?Helen Dickinson, Associate Professor, Public Governance, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/545612016-03-20T19:28:19Z2016-03-20T19:28:19ZNo-one should get dud hospital care – it’s time to lift our game on quality and safety<figure><img src="https://images.theconversation.com/files/115400/original/image-20160317-30211-5g2aov.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some hospitals have substantially higher costs. Others have higher rates of death. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-141478693/stock-photo-writing-on-clipboard-with-patient-in-background-in-hospital.html?src=mCMExOTXOnVDqrAEYkstyA-1-108">racorn/Shutterstock</a></span></figcaption></figure><p>In 2013-14, <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129552833">Australian governments spent A$105 billion on health</a>; A$44 billion of that was on public hospitals. </p>
<p>The Commonwealth government is increasingly concerned with the size of the health budget and has acted to reduce the <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/mbsreviewtaskforce">inappropriate use of Medicare benefits</a>. But the Commonwealth government has less influence on public hospitals because the state and territory governments control their expenditure. </p>
<p>State governments are facing tighter budgets as <a href="https://federation.dpmc.gov.au/increased-demand-leading-rising-health-expenditure">demand for heath care increases</a> due to an ageing population, greater rates of chronic disease and more service use generally. </p>
<p>The collection and analysis of data on the performance of our health-care system can be used to improve the quality of health services and maybe also reduce costs.</p>
<p>At a national level, the clinician-led <a href="http://www.choosingwisely.org.au/">Choosing Wisely campaign</a> is developing lists of specific tests, treatments and procedures that may be unnecessary and sometimes harmful for individual patients. Recommendations include reducing use of CT scans in the emergency department and <a href="https://theconversation.com/antibiotics-for-colds-x-rays-for-bronchitis-internal-exams-with-pap-tests-the-latest-list-of-tests-to-question-56007">not ordering x-rays</a> for patients with uncomplicated acute bronchitis. </p>
<p>But while improving the decisions made by individual doctors is important, there remain other causes of substantial variation in the safety and quality of care provided in Australian hospitals. This needs to be addressed. </p>
<h2>Varied quality and safety</h2>
<p>Efforts to improve the quality of care in hospitals have traditionally been left to individual hospitals and their managers. But we now have the data to compare different hospitals. We can identify the best and worst performers and, most importantly, determine how to boost the performance of the stragglers. </p>
<p>Identifying and intervening to improve low-quality care requires financial investment. But there are significant potential long-term savings, due to improved efficiency and better patient outcomes. </p>
<p>In New South Wales, the <a href="http://www.bhi.nsw.gov.au/publications/the_insights_series/30-day_mortality_in_nsw_for_five_clinical_conditions">Bureau of Health Information</a> has developed and tested methods for comparing the death rates within 30 days of treatment for heart attacks, strokes, pneumonia and hip fracture surgery. </p>
<p>For stroke patients, ten hospitals had noticeably higher-than-expected death rates for these conditions. An additional 16 deaths were observed in every 100 patients treated at a low-performing hospital compared to a high-performing hospital. </p>
<p>Clinical auditors and review panels should investigate differences in the care provided at the high- and low-performing hospitals and approaches to improve care quality. </p>
<p>Other data show the costs of treating similar conditions varies dramatically. A <a href="http://grattan.edu.au/wp-content/uploads/2014/03/806-costly-care.pdf">Grattan Institute analysis</a> shows the average cost of performing a hip replacement at different hospitals ranges from under A$10,000 to more than A$30,000. </p>
<p>Further investigation may find the higher costs are due to the use of more expensive prostheses and to keeping patients in hospital for longer after surgery. Assessments can then be made about whether more expensive prostheses or extended lengths of stay produce better patient outcomes, which justify the additional costs. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/115412/original/image-20160317-30247-28754r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/115412/original/image-20160317-30247-28754r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/115412/original/image-20160317-30247-28754r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/115412/original/image-20160317-30247-28754r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/115412/original/image-20160317-30247-28754r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/115412/original/image-20160317-30247-28754r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/115412/original/image-20160317-30247-28754r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The average cost of hip replacement varies from A$10,000-30,000.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-158329520/stock-photo-midsection-view-of-hands-in-surgical-gloves.html?src=gvoBG1_Kks4jT_O4ZlgKJw-1-52">XiXinXing/Shutterstock</a></span>
</figcaption>
</figure>
<p>We have <a href="http://www.publish.csiro.au/paper/AH15101.htm">analysed hospital data</a> to <a href="https://youtu.be/4B18R5vkeDs">compare costs, outcomes and the care pathways</a> of patients treated for similar conditions at the main public hospitals in South Australia.</p>
<p>After adjusting for differences in the types of patients presenting at emergency departments with chest pain, seven in every 100 patients presenting at a particular hospital were readmitted or died within 12 months. This compared to four to five patients at the other hospitals. </p>
<p>The same hospital spent up to A$669 more on each patient than the other hospitals. Over one year, these additional costs amount to almost A$1 million.</p>
<p>Analysis of the care pathways showed that the hospital with the highest rates of re-admission, premature death and costs, discharged more patients from the emergency department. This hospital also kept patients who were admitted to an inpatient bed in hospital for longer than the other hospitals. </p>
<p>This suggests some patients may have been inappropriately discharged home from the emergency department, while other patients could have been discharged earlier.</p>
<p>Further investigation might look more closely at how and why decisions are made to admit patients from the emergency department and at what might be causing admitted patients to stay longer in hospital.</p>
<h2>Investing in improvement</h2>
<p>State governments are increasingly interested in improving quality. The Queensland government has set up an <a href="https://www.health.qld.gov.au/clinical-practice/innovation/integrated-care/default.asp">Integrated Care Innovation Fund</a> to invest in initiatives to improve efficiency and value. NSW set up a similar <a href="http://www.health.nsw.gov.au/ohmr/Pages/trgs.aspx">Translational Research Grants Scheme</a>. In South Australia, the <a href="http://transforminghealth.sa.gov.au/">Transforming Health</a> initiative aims to improve the quality and consistency of health care across all metropolitan public hospitals.</p>
<p>But while individual efforts to improve quality may have some effect, it is more likely that co-ordinated, systematic approaches will have a greater impact. </p>
<p>Data should be analysed across hospitals on an ongoing basis to identify areas of clinical activity with the greatest potential for improvement, such as the examples above. Findings that quality could be improved should be fed back directly to hospitals. </p>
<p>Specialist teams should be set up to work with hospitals to further investigate areas of concern and to develop and implement improvement strategies. </p>
<p>Rather than going back to the drawing board on health reform, governments need to improve what we’ve already got and bring the poor performing hospitals and departments in line with their better performing peers. </p>
<hr>
<p><em><strong>This article is part of our series <a href="https://theconversation.com/au/topics/hospitals-in-australia">Hospitals in Australia</a>. Click on the links below to read the other instalments:</strong></em></p>
<ul>
<li><p><strong><a href="http://theconversation.com/the-problems-with-australias-hospitals-and-how-can-they-be-fixed-54248">The problems with Australia’s hospitals – and how can they be fixed</a></strong></p></li>
<li><p><strong><a href="http://theconversation.com/infographic-a-snapshot-of-australias-hospitals-56139">Infographic: a snapshot of Australia’s hospitals</a></strong></p></li>
<li><p><strong><a href="http://theconversation.com/from-triage-to-discharge-a-users-guide-to-navigating-hospitals-54658">From triage to discharge: a user’s guide to navigating hospitals</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/how-much-seeing-private-specialists-often-costs-more-than-you-bargained-for-53445">How much?! Seeing private specialists often costs more than you bargained for</a></strong></p></li>
<li><p><strong><a href="http://theconversation.com/why-do-we-wait-so-long-in-hospital-emergency-departments-and-for-elective-surgery-54384">Why do we wait so long in hospital emergency departments and for elective surgery?</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/heres-how-to-boost-hospital-funds-and-end-the-blame-game-54247">Here’s how to boost hospital funds and end the blame game</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/what-are-better-public-or-private-hospitals-54338">What are better, public or private hospitals?</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/do-you-really-need-to-go-to-hospital-time-to-recentre-the-health-system-54406">Do you really need to go to hospital? Time to recentre the health system</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/hospitals-dont-need-increased-funding-they-need-to-make-better-use-of-what-theyve-got-54815">Hospitals don’t need increased funding, they need to make better use of what they’ve got</a></strong></p></li>
</ul><img src="https://counter.theconversation.com/content/54561/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonathan Karnon receives funding from the National Health and Medical Research Council. </span></em></p>There is substantial variation in the safety and quality of care provided in Australian hospitals. The data can tell us why.Jonathan Karnon, Professor of Health Economics, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/547782016-02-23T11:12:24Z2016-02-23T11:12:24ZHospitals rationing drugs behind closed doors: a civil rights issue<p>The United States is facing a shortage of prescription drugs, ranging from antibiotics to cancer treatments. These shortages are putting the medical profession in the frequent position of deciding who will get the drugs that are in short supply and, more importantly, who will not.</p>
<p>Physicians and hospitals always have had to make rationing decisions in times of shortage. But these decisions usually are made behind the scenes. A recent <a href="http://www.nytimes.com/2016/01/29/us/drug-shortages-forcing-hard-decisions-on-rationing-treatments.html?_r=0">New York Times article</a> about the drug shortages shines a light on the rationing that is occurring.</p>
<p>According to the article, the decision-making process varies considerably across institutions. For instance, in some hospitals formal ethics committees make these decisions. At others, these decisions are made by individual physicians, pharmacists or even drug company executives.</p>
<p>And, as the article also reports, patients typically are not told of the shortage and have no idea that their choice of treatment has been limited, even though the decision may delay their recovery, increase their pain or, in some cases, potentially accelerate their death.</p>
<p>As legal experts in medical ethics and disability law who have conducted research on the allocation of medical resources, we were struck by the general lack of awareness of the law evident in the article. The fact is, there are civil rights laws and state laws governing informed consent that apply to such decisions, even in times of public health emergencies and medical shortages.</p>
<p>These laws constrain physician decision-making and must be taken into account on the front end in making treatment or distribution decisions for all patients and in particular, we would argue, for patients with disabilities.</p>
<h2>Bias against people with disabilities</h2>
<p>In 1990, Congress passed the Americans with Disabilities Act (ADA) to provide protection to people with disabilities and assure equal opportunity, access and participation in all areas of public life. The ADA applies to both public and private hospitals, as well as physicians providing care to patients.</p>
<p>The ADA prohibits the use of any eligibility criteria that would screen out people with disabilities from receiving necessary services, including medical care.</p>
<p>But, in the past, drug and treatment allocation protocols or distribution plans created by medical professionals in times of shortage have failed to acknowledge that the ADA limits their discretion.</p>
<p>In 2013, <a href="http://www.floridalawreview.com/wp-content/uploads/2011/06/Hensel_Wolf_BOOK.pdf">we reviewed the allocation protocols</a> developed by public health and medical organizations in providing critical care, such as ventilators, to guide medical decision-making in the event of shortages during an H1NI flu pandemic.</p>
<p>Some of these groups have made recommendations that physicians restrict access to treatment based on patients’ diagnosed disability, their anticipated quality of life, the duration or intensity of their need for care and the treatment effectiveness.</p>
<p>All of these criteria to varying degrees raise the troubling potential for disability bias to play a role.</p>
<p>For example, categorically preventing all individuals with severe mental retardation from all access to ventilators clearly violates the ADA. Likewise, refusing to treat an individual with cystic fibrosis for swine flu because he will still have cystic fibrosis after treatment, and thus a “poor quality of life,” is unlawful.</p>
<p>Quality of life assessments allow the prejudices of health professionals and laypeople, who systematically underestimate the quality of life experienced by people with disabilities, to result in the denial of treatment.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/111694/original/image-20160216-19269-1qna7fo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/111694/original/image-20160216-19269-1qna7fo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/111694/original/image-20160216-19269-1qna7fo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/111694/original/image-20160216-19269-1qna7fo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/111694/original/image-20160216-19269-1qna7fo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/111694/original/image-20160216-19269-1qna7fo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/111694/original/image-20160216-19269-1qna7fo.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">Patients need to know how shortages affect their care.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-361341146/stock-photo-focus-on-hospital-room-sign-with-doctor-talking-to-patient.html?src=742S_EOyhrePk9Lf3ajEkg-1-3">Doctor and patient image via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>To stop bias, decisions should be made in the open</h2>
<p>Given this background, there is little reason to believe that allocation decisions in other situations where medicine or equipment is in short supply will be free from bias against people with disabilities.</p>
<p>The <em>New York Times</em> article coincided with the publication of an ethical framework for <a href="http://jnci.oxfordjournals.org/content/108/6/djv392.full">allocating pediatric cancer drugs</a> in the <em>Journal of the National Cancer Institute.</em> The authors bring attention both to a persistent problem of drug shortages and to the need for a more transparent and inclusive process for deciding who should get rationed drugs.</p>
<p>Although this particular decision framework laudably rejects consideration of disability, it fails to recognize or discuss the fact that such consideration is legally impermissible under the ADA. As to the kinds of <a href="http://www.nytimes.com/2016/01/29/us/drug-shortages-forcing-hard-decisions-on-rationing-treatments.html?_r=0">ad hoc decision-making described in the <em>New York Times</em> article, they</a> are even less likely to appreciate what the ADA requires.</p>
<h2>Secrecy prevents informed consent</h2>
<p>The secrecy surrounding allocation decisions is also in conflict with state laws concerning informed consent.</p>
<p>Patients have a right to know when and why their physicians restrict their access to viable treatment options. State <a href="https://www.law.cornell.edu/wex/tort">tort</a> law governs when a physician must give this information to her patients. Indeed, state courts explicitly lay out when a physician must give this information to her patients.</p>
<p>Just over half the states have adopted <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1280103/">a physician-centered standard</a> that allows the profession to determine when disclosure is desirable. Other states have adopted the more <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1280103/">liberal patient-centered standard</a>, which requires physicians to disclose information that most patients would find relevant to their treatment. Under either standard, physicians have a legal obligation to inform patients of shortages when the shortages affect their care, the risks they face, or their prognosis.</p>
<p>Patients have the right to make informed decisions about their treatment options. This includes knowing when they are being denied effective and otherwise recommended treatment because there is a drug shortage.</p>
<p>The drug shortages are not likely to go away any time soon. Although the medical profession must make hard choices about how to allocate care, these decisions need not and should not be shrouded in mystery.</p>
<p>We need to acknowledge that rationing decisions are being made in the U.S. health system. The limitations on care, the reasons for them and how care will be dispensed should be debated openly.</p>
<p>And those discussions must include the voices of people with disabilities, who so often have been impacted by such decisions. They should also include civil rights experts who can ensure that any allocation protocol incorporates the legal protections society already has put in place.</p>
<p>It is neither fair for physicians to bear this burden alone nor right for people with disabilities unknowingly to be affected at the most fundamental level by decisions made behind closed doors.</p><img src="https://counter.theconversation.com/content/54778/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Although the medical profession must make hard choices about how to allocate care, these decisions need not and should not be shrouded in mystery.Wendy F. Hensel, Associate Dean for Research and Faculty Development and Professor of Law, College of Law, Georgia State UniversityLeslie E. Wolf, Professor of Law and Director, Center for Law Health and Society, College of Law, Georgia State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/142292013-05-17T01:06:14Z2013-05-17T01:06:14ZBreast cancer screening needs to make more than economic sense<figure><img src="https://images.theconversation.com/files/23992/original/tzppfwg9-1368750585.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The harms from over-diagnosis and over-treatment mean that not everyone benefits from breast cancer screening.</span> <span class="attribution"><span class="source">Ian Hunter</span></span></figcaption></figure><p>A <a href="https://theconversation.com/a-rational-expansion-of-breast-cancer-screening-14159">recent article</a> in The Conversation’s <a href="https://theconversation.com/topics/health-rationing">Health Rationing</a> series endorsed the government’s decision to extend the BreastScreen program to women aged 70 to 74 (from 50 to 69), based on the results of a 2009 cost-effectiveness analysis of the program. </p>
<p>But the landscape of breast cancer screening changed irrevocably in late 2012, with the publication of <a href="http://www.cancerresearchuk.org/prod_consump/groups/cr_common/@nre/@pol/documents/generalcontent/breast-screening-review-exec.pdf">a report</a> by an independent UK panel that reviewed breast cancer screening.</p>
<p>The panel confirmed that screening reduces the risk of dying from breast cancer by about 20%, but also concluded that screening causes over-diagnosis. Over-diagnosed cancers are those that would never have been found without screening. They are not destined to cause symptoms or become life-threatening but, nonetheless, they lead to more women getting treatment for breast cancer. </p>
<p>The panel estimated that 681 cancers would be diagnosed for every 10,000 UK women screened from 50 years of age for 20 years. Of these 681 cancers, 129 would represent over-diagnosis and 43 deaths would be prevented. </p>
<p>In other words, for women invited to be screened, the chance of avoiding dying from breast cancer is about 0.4% and the chance of being over-diagnosed and over-treated is about 1.3%. So, for every breast cancer death prevented, three women will be over-diagnosed and over-treated.</p>
<p>Breast cancer screening is a finely balanced trade-off of benefit versus harm. And there are important question marks over the argument to expand the program based on cost-effectiveness analysis alone. </p>
<p>This is particularly problematic because the analysis itself is based solely on survival statistics, when there are also major impacts on quality of life from both potential harms and benefits of screening.</p>
<p>More important than economic considerations, such as whether the program’s “cost per life-year saved” is improved by screening older (or younger) women, is the question - will we do more good than harm by expanding screening?</p>
<p>The <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/br-economic-cnt">2009 cost-effectiveness analysis</a> that was used to assess the implications of expanding the screening program was done as part of a wide-ranging evaluation of the BreastScreen Australia program.</p>
<p>That evaluation also included an assessment of the mortality benefit (percentage of breast cancer deaths averted) by screening in Australia. <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/br-mortality-ecological-cnt">It found</a> that, while screening significantly reduced the risk of dying from breast cancer among women aged 50 to 69 years, there was no significant reduction in breast cancer mortality among women aged 70 to 74 years.</p>
<p>So why have we expanded a program that will likely harm women over the age of 70 through over-diagnosis, without clear evidence that it will deliver a benefit for this age group?</p>
<p>While the 2009 cost-effectiveness estimates included treatment costs, they did not explicitly consider the effects of over-diagnosis and subsequent over-treatment on either survival or on quality of life. </p>
<p>The UK panel’s report suggested that new cost-effectiveness estimates should be made, taking account of over-diagnosis. This needed to be done before the decision to expand the program was made.</p>
<p>The <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/8463830B90E5BDF5CA25762A000193C6/$File/ch%201-3.pdf">2009 BreastScreen Australia Evaluation</a> recommended a focus on increasing screening participation rates through social marketing and other strategies. But is it ethical to promote screening to women in their 70s when we cannot demonstrate that it will reduce the risk of dying of breast cancer in this age group? </p>
<p>Might we not inadvertently pressure older women to undergo breast cancer screening and treatment that they may not need nor benefit from? An example from <a href="http://www.bmj.com/content/346/bmj.f158">recent research</a> conducted by our group is revealing in this regard. </p>
<p>When presented with information about both the benefit of screening and the risk of harm through over-diagnosis, one study participant was angry that she and her mother (aged in her 70s) had not received this information before her mother underwent breast cancer treatment. Her mother died shortly after the operation and our participant believed the death was a direct consequence of treatment.</p>
<p>Breast cancer screening <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/br-economic-cnt">currently costs</a> an average of A$136 million a year. The expansion of the program is being funded at a cost of an additional A$55 million. The opportunity cost (the forgone benefit of alternative use/s of the money spent) of the expansion is considerable. </p>
<p>All things considered, there may be better ways to address the burden of breast cancer that would be more beneficial and less harmful. Such strategies might include more resources directed towards better information about the benefits and harms of screening, as called for by the independent UK panel, to ensure women are able to make informed choices to screen or not. </p>
<p><a href="http://jnci.oxfordjournals.org/content/early/2013/02/01/jnci.djs649">Deliberative methods</a>, such as citizen juries may also be effective way to proceed. These methods allow evidence on complex health decisions to be presented to communities so they can make informed recommendations about where they feel government funds would be best invested. </p>
<p>Better information and better consultation initiatives are priorities for screening programs now that the harm of over-diagnosis has been confirmed. Or, money could be directed to primary prevention of breast cancer through lifestyle modification, breast cancer research or other health-care priorities.</p><img src="https://counter.theconversation.com/content/14229/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alexandra Barratt receives funding from NHMRC for research on the evidence and ethics of cancer screening.</span></em></p><p class="fine-print"><em><span>Kirsten Howard works with the Screening and Test Evaluation Program which is funded by the NHMRC, and receives funding from the ARC.</span></em></p><p class="fine-print"><em><span>Kirsten McCaffery is currently working with the Screening and Test Evaluation Program which has program grant funding from the National Health and Medical Research Council.</span></em></p>A recent article in The Conversation’s Health Rationing series endorsed the government’s decision to extend the BreastScreen program to women aged 70 to 74 (from 50 to 69), based on the results of a 2009…Alexandra Barratt, Professor of Public Health, University of SydneyKirsten Howard, Professor, Health Economics, University of SydneyKirsten McCaffery, NHMRC Career Development Fellow & Associate Professor in Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/141592013-05-13T20:07:12Z2013-05-13T20:07:12ZA rational expansion of breast cancer screening<figure><img src="https://images.theconversation.com/files/23649/original/mzydq554-1368422575.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Based on current evidence, expanding these services is the right thing to do.</span> <span class="attribution"><span class="source">Image from shutterstock.com</span></span></figcaption></figure><p><em>In the ninth part of our series <a href="https://theconversation.com/topics/health-rationing">Health Rationing</a>, Stephen Duckett examines the government’s decision to extend the breast cancer screening program.</em></p>
<hr>
<p>As one of many pre-budget teasers, Health Minister Plibersek <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr13-tp-tp039.htm">announced on Mother’s Day</a> that Australia’s breast screening program will be extended to target women aged 50 to 74 instead of the current age range of 50 to 69.</p>
<p>There may be political benefits from this A$55 million spend, but is it a good deal?</p>
<p>From an economic rationality point of view, the short answer is yes. But there may be a better way to achieve greater gains. </p>
<h2>Is breast screening worth it?</h2>
<p>Australia’s breast screening program was announced by then-prime minister Bob Hawke in the midst of the 1990 election campaign. </p>
<p>But the benefits of the program haven’t been entirely political. A <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/E158C94C6D5FA028CA25762A00029B8A/$File/Econ%20Eval.pdf">2009 cost effectiveness analysis</a> showed that the program cost A$38,302 for each year of life gained. That is a good deal compared to <a href="http://www.sph.uq.edu.au/docs/BODCE/ACE-P/ACE-Prevention_final_report.pdf">other health investments</a>. Dietary counselling from a GP
for people at greater than 5% risk of heart disease, for instance, costs about A$35,000 for every <a href="https://theconversation.com/comparing-apples-pears-and-hips-health-rationing-at-work-13785">disability adjusted life year</a> gained.</p>
<p>Although assumptions in cost effectiveness analysis of breast screening have been challenged because it doesn’t account for the the anxiety <a href="http://www.hta.ac.uk/project/2510.asp">created by screening programs</a>, this report is the best evidence we’ve got.</p>
<p>The government’s decision to extend the age range of women eligible can be seen as economically reasonable because of the reduced cost per year of life gained. Economic rationality and rationing is not a euphemism for budget cutting. Based on current evidence, expanding these services is the right thing to do.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/23639/original/xq982zhy-1368421319.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/23639/original/xq982zhy-1368421319.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/23639/original/xq982zhy-1368421319.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=206&fit=crop&dpr=1 600w, https://images.theconversation.com/files/23639/original/xq982zhy-1368421319.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=206&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/23639/original/xq982zhy-1368421319.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=206&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/23639/original/xq982zhy-1368421319.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=259&fit=crop&dpr=1 754w, https://images.theconversation.com/files/23639/original/xq982zhy-1368421319.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=259&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/23639/original/xq982zhy-1368421319.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=259&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Comparative cost per year of life gained of different policy designs.</span>
<span class="attribution"><span class="source">2009 Cost effectiveness report</span></span>
</figcaption>
</figure>
<p>But here’s the rub. Extending the age range down to 45 and up to 74 is even better on cost-effectiveness criteria. With that policy, the cost per year of life gained from screening would be A$37,612 compared to the current A$38,302 – a 2% improvement. Small, yes, but important in the overall scheme of things.</p>
<p>Cost effectiveness isn’t the only relevant criterion, though, even for the econocrat. Extending the age range both upward and downward would cost much more money than just an upward change. In tight budgetary times the larger extension, although economically worthwhile, may have been a budget step too far.</p>
<h2>Roads not taken</h2>
<p>Yet, if increasing the age range were combined with efforts to cut the cost of screening, we might be able afford the best of both worlds: even more breast cancer screening without hurting the budget bottom line. Cost-effective expansions and budget integrity might both have been feasible.</p>
<p>The 2009 cost effectiveness report also examined changes to current practice and identified several ways to save money, while still saving lives. Increasing the screening interval from two to three years is certainly cost effective and would save significantly on budget outlays. The government could easily afford an age range expansion in both directions if that change were implemented.</p>
<p>Changes in who can conduct and read mammograms are also cost effective. Currently, every mammogram is examined independently by two radiologists. One cheaper and more cost-effective option assessed was to have the second reading done by a specially trained reader. Changes in who takes the mammograms – a radiographer assistant rather than a radiographer – would also lower costs.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/23640/original/8ccdrt56-1368421319.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/23640/original/8ccdrt56-1368421319.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/23640/original/8ccdrt56-1368421319.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=361&fit=crop&dpr=1 600w, https://images.theconversation.com/files/23640/original/8ccdrt56-1368421319.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=361&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/23640/original/8ccdrt56-1368421319.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=361&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/23640/original/8ccdrt56-1368421319.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=454&fit=crop&dpr=1 754w, https://images.theconversation.com/files/23640/original/8ccdrt56-1368421319.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=454&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/23640/original/8ccdrt56-1368421319.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=454&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></span>
</figcaption>
</figure>
<p>There is still some controversy about breast screening and new evidence is becoming available every day. The 2009 cost-effectiveness study was a “modelling” study, not an assessment in the real world.
In contrast to the Australian approach of simply announcing an expansion of breast screening, a similar expansion in the English National Health Service was accompanied by a <a href="http://www.controlled-trials.com/ISRCTN33292440">randomised controlled trial</a> to allow a full evaluation of the new policy. </p>
<p>It’s puzzling why a similar strategy was not followed here, especially in the light of <a href="http://www.mckeonreview.org.au/">recent calls</a> for more health services research in Australia to contribute to policy development.</p>
<h2>Burgeoning health outlays</h2>
<p>Health expenditure is <a href="https://theconversation.com/tough-choices-how-to-rein-in-australias-rising-health-bill-13658">rising rapidly</a>. Budget setting is about priority setting (the soft way to say “rationing”). But the rationing discussion should follow, not replace or precede, the efficiency discussion. The extra money to expand screening to wider age groups could have been offset completely by improved efficiency.</p>
<p>Current policy settings in breast screening “ration” the public program to women aged 50-69. The government has just announced a new “rationing” regime, to target women 50-74, and this indeed is a rational expansion, as far as it goes.</p>
<p>But the real rationing question is: in hard economic times, why aren’t we pursuing other breast-screening initiatives – such as changing the screening interval and using a different mix of health professionals – that are more economically rational and save more money?</p>
<p><strong><em>This is the ninth part of our series <a href="https://theconversation.com/topics/health-rationing">Health Rationing</a>. Click on the links below to read the other instalments:</em></strong></p>
<p><strong>Part one:</strong> <a href="https://theconversation.com/tough-choices-how-to-rein-in-australias-rising-health-bill-13658">Tough choices: how to rein in Australia’s rising health bill</a><br> <strong>Part two:</strong> <a href="https://theconversation.com/explainer-what-is-health-rationing-13667">Explainer: what is health rationing?</a><br>
<strong>Part three:</strong> <a href="https://theconversation.com/a-conversation-that-promises-savings-worth-dying-for-13710">A conversation that promises savings worth dying for</a><br>
<strong>Part four:</strong> <a href="https://theconversation.com/phase-out-gp-consultation-fees-for-a-better-medicare-13690">Phase out GP consultation fees for a better Medicare</a><br>
<strong>Part five:</strong> <a href="https://theconversation.com/focus-on-prevention-to-control-the-growing-health-budget-13665">Focus on prevention to control the growing health budget</a><br>
<strong>Part six:</strong> <a href="https://theconversation.com/health-funding-under-the-microscope-but-what-should-we-pay-for-13788">Health funding under the microscope – but what should we pay for?</a><br>
<strong>Part seven:</strong> <a href="https://theconversation.com/comparing-apples-pears-and-hips-health-rationing-at-work-13785">Comparing apples, pears and hips: health rationing at work</a><br>
<strong>Part eight:</strong> <a href="https://theconversation.com/who-gets-a-piece-of-the-pie-spending-the-health-budget-fairly-13997">Who gets a piece of the pie? Spending the health budget fairly</a></p><img src="https://counter.theconversation.com/content/14159/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Duckett does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In the ninth part of our series Health Rationing, Stephen Duckett examines the government’s decision to extend the breast cancer screening program. As one of many pre-budget teasers, Health Minister Plibersek…Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/139972013-05-12T20:08:40Z2013-05-12T20:08:40ZWho gets a piece of the pie? Spending the health budget fairly<figure><img src="https://images.theconversation.com/files/23532/original/yn5tv8f4-1368335371.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Health-services research can help work out how best to share the health-funding pie.</span> <span class="attribution"><span class="source">Wout/Flickr</span></span></figcaption></figure><p><em>In the eighth part of our series <a href="https://theconversation.com/topics/health-rationing">Health Rationing</a>, Philip Clarke and Nicholas Graves suggest ways to make the health-care system more efficient and affordable.</em></p>
<hr>
<p>Who would want be the health minister? If anyone is considering the job, they should watch the <a href="https://theconversation.com/qandas-health-debate-the-experts-respond-13685">recent episode</a> of <a href="http://www.abc.net.au/tv/qanda/txt/s3732232.htm">ABC TV’s Q&A</a> when Commonwealth Minister for Health Tanya Plibersek and the Shadow Minister Peter Dutton faced questions from key stakeholder groups.</p>
<p>With one or two exceptions, almost all questions were the same: my issue is X, so when will the government spend millions and, in some cases, billions of extra dollars to address my problem?</p>
<p>Governments have responded to this type of lobbying in the good times by spending more money, but we now live in much more difficult times. Scarcity of resources is biting hard, and the government expects budget deficits over the next few years.</p>
<p>The correct answer for the health minister to questions from stakeholders would now be that we need to allocate the funds we have more efficiently, so we can find the money for new projects. When we fund these projects we need to ensure they represent value for money.</p>
<p>Economists think about efficiency in two complementary ways. Allocative efficiency is where we are “doing the right things” and choosing the best mix of services to provide. Technical efficiency is “doing things right” and producing the best mix of services at the lowest possible cost. Both are required for the health-care system to be efficient overall.</p>
<p>There’s no better example of technical inefficiency in our health-care system than the way we set prices for generic drugs on the Pharmaceutical Benefits Scheme (PBS). Australians are paying some of the highest prices in the world for generic medications because of poor policy decisions as detailed in a recent <a href="http://ceda.com.au/">report</a> by the independent think tank Committee for Economic Development of Australia (CEDA). If we could improve our purchasing of generic drugs, more than a billion dollars extra a year could be released for other uses.</p>
<p>Australia prides itself on being one of the first countries to try to improve allocative efficiency by explicitly using economic evaluation when listing new drugs on the PBS. But the use of these methods is more the exception than the rule when making health-care decisions.</p>
<p>For instance, there’s no systematic attempt to evaluate hospital-based interventions to determine the ones that are the most cost-effective.</p>
<p>So where do we go from here? It is worth looking at the recently released <a href="http://www.mckeonreview.org.au/">McKeon Strategic Review of Health and Medical Research</a>, which concerned itself with making stronger connections between research evidence and the delivery of health-care services. The report flags building capacity among health economists and health-services researchers in Australia as crucial for improving health services.</p>
<p>A systematic program of health-services research is one way of separating vested interests from those of the whole community. Having academics undertake most this research is critical because unlike consultants, academics must test the evidence for any proposed policy changes through peer review and can come up with new solutions that go against the prevailing wisdom.</p>
<p>If our goal is to connect health economics and health-services research with clinicians and decision-makers, then existing ways of working are likely to be insufficient. The main approach identified in the review is to expand <a href="http://www.nhmrc.gov.au/">National Health and Medical Research Council</a> (NHMRC) funding in this area, and the creation of an institute of health-services research.</p>
<p>But we have been here before. Over the years, the NHMRC has introduced various initiatives, including several rounds of funding specifically for health economics and health-services research. Such funding generally goes to only a few groups and they have a maximum of five years’ funding to develop a research agenda.</p>
<p>We think an entirely different mode of funding is required and we could learn much from the <a href="http://www.nihr.ac.uk/Pages/default.aspx">National Institute of Health Research</a> (NIHR) in England.</p>
<p>The main role of NIHR is to commission policy-relevant research through boards that involve academics, policy makers and those involved in service delivery. This ensures the questions researchers are addressing are relevant to current decisions.</p>
<p>And having commissioning boards means there’s a separation between those commissioning work and those undertaking it. This makes the funding of health services-research in England flexible, transparent and competitive.</p>
<p>Another crucial feature of the English system is the framework for dissemination. While all researchers are encouraged to publish their commissioned research in peer-reviewed journals, the final report is published in its own <a href="http://www.hta.ac.uk/research/HTAjournal.shtml">Health Technology Assessment</a> journal. This ensures the findings of all past research can be found in one place. It also helps avoid duplication and makes it very easy for a policy maker to find relevant research on any topic.</p>
<p>We don’t want to sound like another lobby group asking for more money, so we suggest the funding for the expansion of health-services research should come largely from existing resources, such as the $40 to $50 million a year the commonwealth department of health currently spends on consultants. Setting up the right processes rather than the level of funding is likely to produce more bang for your health-services research buck.</p>
<p>An effective Australian health-services research institute would help future health ministers provide better answers to the kinds of questions they will face on shows like Q&A.</p>
<p><br>
<em><strong>This is the eighth part of our series <a href="https://theconversation.com/topics/health-rationing">Health Rationing</a>. Click on the links below:</strong></em></p>
<p><strong>Part one:</strong> <a href="https://theconversation.com/tough-choices-how-to-rein-in-australias-rising-health-bill-13658">Tough choices: how to rein in Australia’s rising health bill</a><br>
<strong>Part two:</strong> <a href="https://theconversation.com/explainer-what-is-health-rationing-13667">Explainer: what is health rationing?</a><br>
<strong>Part three:</strong> <a href="https://theconversation.com/a-conversation-that-promises-savings-worth-dying-for-13710">A conversation that promises savings worth dying for</a><br>
<strong>Part four:</strong> <a href="https://theconversation.com/phase-out-gp-consultation-fees-for-a-better-medicare-13690">Phase out GP consultation fees for a better Medicare</a><br>
<strong>Part five:</strong> <a href="https://theconversation.com/focus-on-prevention-to-control-the-growing-health-budget-13665">Focus on prevention to control the growing health budget</a><br>
<strong>Part six:</strong> <a href="https://theconversation.com/health-funding-under-the-microscope-but-what-should-we-pay-for-13788">Health funding under the microscope – but what should we pay for?</a><br>
<strong>Part seven:</strong> <a href="https://theconversation.com/comparing-apples-pears-and-hips-health-rationing-at-work-13785">Comparing apples, pears and hips: health rationing at work</a>r</p><img src="https://counter.theconversation.com/content/13997/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Prof Philip Clarke receives funding from the Australian National Health and Medical Research Council (NHMRC), the English National Institute for Health Research (NIHR), the United States National Institute for Health (NIH) and various Swedish Research Councils. Given that his research relates involves health economics, he may benefit from an expansion of health services research funding in Australia.</span></em></p><p class="fine-print"><em><span>Nicholas Graves receives funding from ARC, NHMRC, NIHR, QLD Government. He is the academic director of the Australian Centre for Health Services Innovation.</span></em></p>In the eighth part of our series Health Rationing, Philip Clarke and Nicholas Graves suggest ways to make the health-care system more efficient and affordable. Who would want be the health minister? If…Philip Clarke, Professor of Public Health, The University of MelbourneNicholas Graves, Professor of Health Economics, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/137852013-05-08T20:53:33Z2013-05-08T20:53:33ZComparing apples, pears and hips: health rationing at work<figure><img src="https://images.theconversation.com/files/23327/original/35mwyvdz-1367971535.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Health rationing assessments compare different aspects of health such as pain, anxiety, mobility and social interactions – but what's more important?</span> <span class="attribution"><span class="source">Image from shutterstock.com</span></span></figcaption></figure><p><em>In the seventh part of our series <a href="https://theconversation.com/topics/health-rationing">Health Rationing</a>, Richard Norman and Rosalie Viney explain the controversial system governments use to decide what will and won’t be covered under Australia’s universal health system.</em></p>
<hr>
<p>With <a href="https://theconversation.com/tough-choices-how-to-rein-in-australias-rising-health-bill-13658">finite health budgets</a> and the prospect of infinite ways to spend funds, <a href="https://theconversation.com/explainer-what-is-health-rationing-13667">rationing inevitably occurs</a>. But how do policymakers come to decisions about what types of care, medications or services to subsidise, and those that don’t make the cut? </p>
<p>They use a framework called <a href="http://www.health.gov.au/internet/hta/publishing.nsf/Content/about-1">Health Technology Assessment</a> (HTA), which the government describes as a key tool “to deliver a safe, effective and efficient health system that is fiscally sustainable in the longer term”.</p>
<p>But it’s certainly not a perfect system – far from it. </p>
<p>When HTA is used make decisions in a third party-payer system (such as Medicare or private health funds), there is an explicit link between access to care and the cost-effectiveness of the treatment. This leads to the possible denial of access to a potentially effective intervention because it is considered too costly. </p>
<p>The aim of HTA is to identify the set of health services that represent the best buys for society. But the process is far from transparent. </p>
<p>So how does the HTA process work, and what makes it so controversial?</p>
<h2>Describing and valuing health</h2>
<p>To work out what the best bundle of health services is, policymakers need to be able to compare the health benefits that each service provides. While the costs of interventions can be boiled down to a single dollar value, doing so for their impact on health is much harder. </p>
<p>How can you sensibly judge whether a healthy lifestyle program is more or less valuable for the population than funding hip replacements? Both may have demonstrated positive impacts on health but their benefits manifest in very different ways, to different people and over different time horizons. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/23334/original/bxrts3vz-1367975264.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/23334/original/bxrts3vz-1367975264.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=980&fit=crop&dpr=1 600w, https://images.theconversation.com/files/23334/original/bxrts3vz-1367975264.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=980&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/23334/original/bxrts3vz-1367975264.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=980&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/23334/original/bxrts3vz-1367975264.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1232&fit=crop&dpr=1 754w, https://images.theconversation.com/files/23334/original/bxrts3vz-1367975264.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1232&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/23334/original/bxrts3vz-1367975264.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1232&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">How do you compare the value of a hip replacement with a healthy lifestyle program?</span>
<span class="attribution"><span class="source">Image from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Some interventions improve life expectancy, some improve quality of life, and some improve both. To make these comparisons possible, the solution in HTA is to use a measure that combines quality of life and survival to compare treatments. A common one is called the <a href="http://www.health.gov.au/internet/publications/publishing.nsf/Content/illicit-pubs-needle-return-1-rep-toc%7Eillicit-pubs-needle-return-1-rep-5%7Eillicit-pubs-needle-return-1-rep-5-2">quality-adjusted life year</a> (QALY).</p>
<p>To make the comparison across diseases and treatments valid, policymakers have to describe health in a way general enough to capture their diverse effects of health and quality of life – for example, thinking about different aspects of health such as pain, anxiety, mobility and social interaction. </p>
<p>However, the description of health in a generic way is fraught with difficulty. There is an alphabet soup of surveys that have been designed specifically for use in HTA (EQ-5D, SF-6D, HUI, AQoL and so on), each of which aims to be general but inevitably places a different emphasis on different areas of health. </p>
<p>If policymakers use a survey which explicitly considers vision, for instance, the effect of a treatment for <a href="http://www.mayoclinic.com/health/macular-degeneration/DS00284">macular degeneration</a> (an eye disease that causes blindness) may be measured very differently than if they use a survey that focuses on mobility and function. The result could be that the choice of survey affects how effective and cost-effective the treatment ends up being in the HTA process.</p>
<p>In addition to the issue of picking a survey for describing health in this general way, policymakers then have to consider how people value different aspects of health, including life expectancy and the different aspects of quality of life. </p>
<p>Is avoiding pain more or less important than avoiding depression? This is usually explored by asking people to state their willingness to trade off something (often <a href="http://www.ncbi.nlm.nih.gov/pubmed/21914515">life expectancy</a> or risk of death) to improve their quality of life.</p>
<p>The methodological issues around such a process are considerable, and introduce further uncertainty into the process.</p>
<h2>Societal decision-making</h2>
<p>If the policymakers manage to pick a survey they believe is capable of capturing changes in health, and can estimate these combined outcomes (like the QALY), they then have to make assumptions about what we as a society should do with this information. </p>
<p>HTA is typically based on the premise that we aim to maximise the total health of the population. While this is a reasonable starting point, there are many aspects of health gain that it doesn’t capture. </p>
<p>Do we not care who gets the health improvement? Do we think that people have a right to a “fair innings”, and resources should be targeted to maximise their chances of doing so? </p>
<p>Studies by researchers at <a href="http://www.ncbi.nlm.nih.gov/pubmed/21310500">Monash University</a> and the <a href="http://www.ncbi.nlm.nih.gov/pubmed/22529053">University of Technology Sydney</a> have found Australians generally prefer to target health resources in favour of people with poorer health, even if this means less health gain overall. </p>
<p>Current models of HTA do not consider this, and therefore we rely on decision-makers to informally balance issues of efficiency and equity. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/23336/original/f4cynywg-1367975763.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/23336/original/f4cynywg-1367975763.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/23336/original/f4cynywg-1367975763.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/23336/original/f4cynywg-1367975763.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/23336/original/f4cynywg-1367975763.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/23336/original/f4cynywg-1367975763.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/23336/original/f4cynywg-1367975763.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Australians prefer to target health resources in favour of people with poorer health.</span>
<span class="attribution"><span class="source">Image from shutterstock.com</span></span>
</figcaption>
</figure>
<p>A further issue is that many outcomes we value in the health system are not well captured in conventional HTA. We place a high value on reassurance, such as knowing you don’t have a particular genetic mutation before you have children, but this is not readily captured in the existing measures of quality of life. </p>
<p>There are a variety of non-health outcomes (such as convenience of treatment) which are similarly not well-dealt with. Whether they can be included in HTA remains a live issue, and, in the specific case of genetic mutations, one which is likely to become more important given the medical profession’s understanding of the human genome is likely to open up a range of new risk assessment tools.</p>
<p>There are many limitations to how we, as a society, identify best buys in health care. And the impact of quite abstract concepts on HTA results can be large. </p>
<p>But this should not, and indeed cannot, dissuade us from pursuing a sensible, transparent and consistent approach to evaluating health-care interventions. </p>
<p><em><strong>This is the seventh part of our series <a href="https://theconversation.com/topics/health-rationing">Health Rationing</a>. Stay tuned for more articles in the lead up to the May budget or click on the links below:</strong></em></p>
<p><strong>Part one:</strong> <a href="https://theconversation.com/tough-choices-how-to-rein-in-australias-rising-health-bill-13658">Tough choices: how to rein in Australia’s rising health bill</a><br>
<strong>Part two:</strong> <a href="https://theconversation.com/explainer-what-is-health-rationing-13667">Explainer: what is health rationing?</a><br>
<strong>Part three:</strong> <a href="https://theconversation.com/a-conversation-that-promises-savings-worth-dying-for-13710">A conversation that promises savings worth dying for</a><br>
<strong>Part four:</strong> <a href="https://theconversation.com/phase-out-gp-consultation-fees-for-a-better-medicare-13690">Phase out GP consultation fees for a better Medicare</a><br>
<strong>Part five:</strong> <a href="https://theconversation.com/focus-on-prevention-to-control-the-growing-health-budget-13665">Focus on prevention to control the growing health budget</a><br>
<strong>Part six:</strong> <a href="https://theconversation.com/health-funding-under-the-microscope-but-what-should-we-pay-for-13788">Health funding under the microscope – but what should we pay for?</a></p><img src="https://counter.theconversation.com/content/13785/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rosalie Viney has received funding from the NHMRC for a project to develop methods of valuing health outcomes.
Rosalie Viney is a member of the Pharmaceutical Benefits Advisory Committee (PBAC). The views in this article do not necessarily represent the views of the PBAC or the Australian Government Department of Health and Ageing</span></em></p><p class="fine-print"><em><span>Richard Norman 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 the seventh part of our series Health Rationing, Richard Norman and Rosalie Viney explain the controversial system governments use to decide what will and won’t be covered under Australia’s universal…Richard Norman, Senior Research Fellow in Health Economics, University of Technology SydneyRosalie Viney, Professor of Health Economics, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/137882013-05-08T04:29:05Z2013-05-08T04:29:05ZHealth funding under the microscope – but what should we pay for?<figure><img src="https://images.theconversation.com/files/23287/original/gfdh8bjq-1367880437.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The health budget isn't limitless: decisions have to be made about to how to allocate funding between competing choices.</span> <span class="attribution"><span class="source">AAP/Dave Hunt</span></span></figcaption></figure><p><em>In the sixth part of our series <a href="https://theconversation.com/topics/health-rationing">Health Rationing</a>, Mark Mackay examines the latest think tank blueprint to rein in Australia’s rising health costs. But he warns that before funding models are adjusted, governments must make some tough decisions about the type of health care they’re willing to pay for.</em></p>
<hr>
<p>In recent weeks, the <a href="http://www.ceda.com.au/media/302619/healthcarefinal1.pdf">Committee for Economic Development Australia</a> and the <a href="http://grattan.edu.au/publications/reports/post/budget-pressures-on-australian-governments/">Grattan Institute</a> released reports on Australia’s rising health costs and strategies to rein them in. Now the <a href="http://www.cis.org.au/">Centre for Independent Studies</a> has released its own blueprint for health financing reform: <a href="http://cis.org.au/publications/target30-research-papers/article/4784-saving-medicare-but-not-as-we-know-it#http://cis.org.au/publications/target30-research-papers/article/4784-saving-medicare-but-not-as-we-know-it">Saving Medicare but not as we know it</a>. </p>
<p>The report is part of the centre’s TARGET30 campaign, aimed at reducing the size of the government, while improving public services and reducing fiscal burdens on future generations. </p>
<p>To transform Australia’s financially unsustainable health system, the centre recommends cutting Medicare (Australia’s free and universal taxpayer-funded health care scheme) “down to size” by boosting the efficiency of public health services, better targeting public health spending and expanding the role played by private health-care financing. </p>
<p>Essentially, this means the individual becomes more responsible for meeting their own health costs and that hospitals are made more efficient. </p>
<p>The centre also recommends scrapping certain programs or aspects of Medicare in order to reduce wasteful expenditure. These include <a href="http://www.humanservices.gov.au/customer/services/medicare/chronic-disease-management-plan">GP management plans</a>, where doctors are paid to coordinate the care of patients with a chronic illness and the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-ba-fact-transfac">Better Access</a> program, which pays for up to ten consultations with a psychologist.</p>
<h2>Health savings accounts</h2>
<p>One of the key recommendations in the report is the introduction of a dual funding system. Rather than relying on Medicare for seemingly free or low-cost services, people would use individual “health saving accounts” to pay for their own low-cost health care. For high-cost episodes of care, such as operations, government-issued vouchers would be available. </p>
<p>Health savings accounts are like superannuation accounts, but are used to pay for health-care services from adulthood to death. The system is currently used in the Netherlands, where half of the funds come from employers, 45% come from the insured person and 5% by the government.</p>
<p>But while the centre points to the experience of the Dutch as being a way forward, the system has only been in operation since 2006. It is therefore too early to determine how well costs are being contained and how well the system compares with other countries.</p>
<p>This is not to say that health savings accounts aren’t worthy of consideration. Rather, there’s a good deal more to discuss before the proposal can be accepted.</p>
<h2>What should we pay for?</h2>
<p>Australia, like many other OECD countries, is experiencing increasing cost pressures from its health-care delivery system. Money is not limitless and decisions have to be made about to how to allocate funding between competing choices that governments wish to fund.</p>
<p>The centre is right in saying it’s now time to act, otherwise we will be merely repeating mistakes of the past. But this involves first deciding what might be purchased and then deciding how those purchases should be funded. </p>
<p>The centre’s report has jumped to the funding decision first without considering whether we have decided to purchase the right thing. Altering the funding mechanism to purchase the wrong mix of health-care “products” is not a good decision. We want to purchase good health outcomes and not just health service activity.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/23312/original/x5hgyys7-1367905303.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/23312/original/x5hgyys7-1367905303.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/23312/original/x5hgyys7-1367905303.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/23312/original/x5hgyys7-1367905303.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/23312/original/x5hgyys7-1367905303.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/23312/original/x5hgyys7-1367905303.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/23312/original/x5hgyys7-1367905303.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Elderly people with kidney disease are increasingly treated with dialysis – but will it improve their quality of life?</span>
<span class="attribution"><span class="source">Image from shutterstock.com</span></span>
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</figure>
<p>Last week on The Conversation, intensive care specialist Peter Saul <a href="https://theconversation.com/a-conversation-that-promises-savings-worth-dying-for-13710">argued </a> it was time to address the decisions we make about care options, particularly towards the end of life. </p>
<p>South Australian Minister for Health and Ageing made a similar call when addressing two <a href="http://www.ceda.com.au/news-articles/2013/04/18/health_sa#http://www.ceda.com.au/news-articles/2013/04/18/health_sa">public forums</a> in Adelaide earlier this month:
“It’s time for a mature debate about what the public wants and what they are willing to pay for in healthcare and other areas,” he said. </p>
<p>The minister identified that the expansion of services in recent years, such as the regular provision of dialysis for the elderly, has been costly and has occurred without regard to the quality of life impact. Notably, the <a href="http://www.aihw.gov.au/use-of-hospital-services/#http://www.aihw.gov.au/use-of-hospital-services/%20">single greatest reason for hospital admission</a> during 2004-05 was for “care involving dialysis”, an indicator for chronic kidney disease, which accounted for nearly 12% of admissions. </p>
<p>Like Saul, the minister has suggested that, “the value of health spending needed to be re-cast in terms of the quality of survival rather than survival alone”. </p>
<p>While experts are highlighting the need to consider conversations around end-of-life options, the real challenge lies ahead for community leaders. Are they prepared to provide the leadership to see such changes come to fruition and not buckle under the weight of political or media pressure about hospital beds, waiting times and staffing numbers?</p>
<p>There’s no such thing as a free lunch. We will all pay for today’s bad decisions in the future – and it just so happens that the medical profession can now keep us alive longer to see the outcome of these decisions. It’s time to determine what health outcomes we need and want, and how we might then deliver and fund these in a sustainable way. </p>
<p>But what we’re lacking is someone to stand up and lead the engagement process. Who is prepared to deliver and implement the necessary changes to our health system? And will they be able to muster the politicians, media and the public along for the journey? </p>
<p>Given the different levels of government that have responsibility for delivering health-care services in Australia, achieving change will require champions to take up the challenges in each state and territory as well.</p>
<p>Economists alone cannot, nor should they be expected to, provide the solution to Australia’s health system’s problems. The centre’s TARGET30 report does, however, provide a talking point – and that’s where engagement begins.</p>
<p><em><strong>This is the sixth part of our series <a href="https://theconversation.com/topics/health-rationing">Health Rationing</a>. Stay tuned for more articles in the lead up to the May budget or click on the links below:</strong></em></p>
<p><strong>Part one:</strong> <a href="https://theconversation.com/tough-choices-how-to-rein-in-australias-rising-health-bill-13658">Tough choices: how to rein in Australia’s rising health bill</a><br>
<strong>Part two:</strong> <a href="https://theconversation.com/explainer-what-is-health-rationing-13667">Explainer: what is health rationing?</a><br>
<strong>Part three:</strong> <a href="https://theconversation.com/a-conversation-that-promises-savings-worth-dying-for-13710">A conversation that promises savings worth dying for</a><br>
<strong>Part four:</strong> <a href="https://theconversation.com/phase-out-gp-consultation-fees-for-a-better-medicare-13690">Phase out GP consultation fees for a better Medicare</a><br>
<strong>Part five:</strong> <a href="https://theconversation.com/focus-on-prevention-to-control-the-growing-health-budget-13665">Focus on prevention to control the growing health budget</a></p><img src="https://counter.theconversation.com/content/13788/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Mackay is also a Director of Complete the Picture Consulting Pty Ltd.</span></em></p>In the sixth part of our series Health Rationing, Mark Mackay examines the latest think tank blueprint to rein in Australia’s rising health costs. But he warns that before funding models are adjusted…Mark Mackay, Senior Lecturer, Health Care Management, School of Medicine, Flinders UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/136652013-05-01T20:10:58Z2013-05-01T20:10:58ZFocus on prevention to control the growing health budget<figure><img src="https://images.theconversation.com/files/23110/original/hhgsmwvb-1367386016.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Preventative health programs, like the one against skin cancer, aresuccessful and highly cost effective.</span> <span class="attribution"><span class="source">Chelsea Nesvig</span></span></figcaption></figure><p>Australia spends more than $130 billion each year on health, approximately 9.2% of our GDP. The outcome of this and other investments is that our life expectancy puts us very high on the global “league table”.</p>
<p>But a recent <a href="http://grattan.edu.au/static/files/assets/ff6f7fe2/187_budget_pressures_report.pdf">Grattan Institute report</a> has pointed out that health expenditure is one of the major drivers of budget deficits. Growth in health spending above GDP over the past ten years was greater than the growth above GDP of all other spending combined. </p>
<p>There’s growing concern across the community that we will have to ration our health resources. We already do, quite profoundly. But there are areas of waste. The fact that “Australia is paying more than $1.3 billion a year too much” for our national pharmaceutical bill as outlined in <a href="http://grattan.edu.au/publications/reports/post/australias-bad-drug-deal/">another Grattan report</a> means this money could be spent on better care and prevention. </p>
<p>This is particularly true for those with least access to health-care services. As a nation steadfastly (rhetorically at least) committed to justice and egalitarianism, this money could be much more fairly and effectively spent on a national oral health-care program or make a major contribution to the national disability insurance scheme.</p>
<p>It isn’t only the drug bill where we could save billions but also in the area of medical diagnosis and intervention. A recent <a href="https://www.mja.com.au/journal/2012/197/10/over-150-potentially-low-value-health-care-practices-australian-study">article in the Medical Journal of Australia</a> outlined some of the 150 potentially low-value health-care practices that doctors could be discouraged to use. Among these are included arthroscopic surgery for knee osteo-arthritis and caesarean sections without a medical reason for it. </p>
<p>Then there are the futile end-of-life treatments on which we spend enormous amounts even though they neither enhance nor prolong life. Elderly patients with <a href="http://www.dartmouthatlas.org/downloads/reports/Cancer_report_11_16_10.pdf">poor prognosis cancer</a> should not be spending their last days in intensive care units, receiving “…advanced life support interventions such as endotracheal intubation, feeding tubes and cardiopulmonary resuscitation (CPR).” </p>
<p>There is also the wasted spending on poorly-designed and poorly-researched public education campaigns, such as the <a href="http://swapit.gov.au/">Swap it, Don’t Stop</a> it campaign.</p>
<p>But can we spend more wisely and, at the same time, get better outcomes? Although most would happily agree with Benjamin Franklin’s adage that “an ounce of prevention is worth a pound of cure”, we fail to invest in accordance with this saying. In fact, we do exactly the opposite.</p>
<p>There are a few areas where we could be much smarter and, not surprisingly, they are in prevention. As one of the best researchers in epidemiology Geoffrey Rose said, “It is better to be healthy than be ill or dead. That is the beginning and the end of the only real argument for preventative medicine. It is sufficient.”</p>
<p>So where have preventative health’s “best buys” been and what are the some of the others? There are many – tobacco control, road trauma prevention, skin cancer and immunisation to name a few. These have all had great returns on investment, and their aim was not only to prolong life but to enhance its quality. </p>
<p>Skin cancers are among the most costly of cancers, and <a href="http://www.ncbi.nlm.nih.gov/pubmed/19747936">prevention programs</a>, such as Sun Smart, have been repeatedly shown to be successful (averting more than 100,000 skin cancers between 1988 and 2003 in Victoria alone) and highly cost effective. These programs have a return of $3.60 for every dollar invested.</p>
<p>What simple things could we be doing?</p>
<p>Salt is a major contributor to high blood pressure, which, in turn, is a major cause of strokes and heart attacks. We could reduce salt in our food without really noticing. It’s <a href="http://www.georgeinstitute.org.au/media-releases/less-salt-please-especially-for-our-children">been estimated</a> that $20 million spent on a national food reformulation campaign to reduce salt would get us the same health improvements as $1.5 billion spent on antihypertensive drugs.</p>
<p>Reducing children’s exposure to junk food advertising would the cheapest and most effective way to reduce obesity. Australian children are currently exposed to extremely powerful, pervasive and “nannying” advertising that is much more powerful than any ads governments have ever been able to produce. This year, summer was brought to us by McDonalds, Joyville by Cadburys and happiness came to us courtesy of Coca Cola. How lucky we are.</p>
<p>According the <a href="http://www.publichealthnewswire.org/?p=7079">American Public Health Association</a>, if 10% of US adults began walking regularly, they could avoid $5.6 billion in heart disease costs. Every $1 invested in a child safety seat saves $42 in prevented medical costs, and routine childhood immunisation programs save 33,000 lives.</p>
<p>Listen to those who, besides government, bear the risk of spiralling health care costs – business and the insurance industry. We can learn from the United States where health-care costs are rocketing. </p>
<p>A <a href="https://www.metlife.com/assets/cao/mmi/publications/studies/2013/mmi-health-status-implications-40-population.pdf">recent report</a> by MetLife (a very large US Insurance company), talks of a potential health “train wreck” in the near future. It states that this could be mitigated by increases in education, health literacy and prevention, particularly in workplaces. One health and well-being program they describe reduced absenteeism by 80% and saved $1.5 million in salaries. </p>
<p>If Australia is to get better health outcomes at a time of fiscal constraints, it will need to make tough decisions. Surprisingly, many of these decisions won’t cost much and may even raise money (tobacco taxation and reducing salt for instance). Taking heed of Benjamin Franklin and practicing what he preached would be a great start.</p>
<p><strong><em>This is the fifth part of our series <a href="https://theconversation.com/topics/health-rationing">Health Rationing</a>. Stay tuned for more articles in the lead up to the May budget or click on the links below:</em></strong></p>
<p><strong>Part one:</strong> <a href="https://theconversation.com/tough-choices-how-to-rein-in-australias-rising-health-bill-13658">Tough choices: how to rein in Australia’s rising health bill</a><br>
<strong>Part two:</strong> <a href="https://theconversation.com/explainer-what-is-health-rationing-13667">Explainer: what is health rationing?</a><br>
<strong>Part three:</strong> <a href="https://theconversation.com/a-conversation-that-promises-savings-worth-dying-for-13710">A conversation that promises savings worth dying for</a><br>
<strong>Part four:</strong> <a href="https://theconversation.com/phase-out-gp-consultation-fees-for-a-better-medicare-13690">Phase out GP consultation fees for a better Medicare</a> </p><img src="https://counter.theconversation.com/content/13665/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rob Moodie has received funding from Department of Health and Ageing. He is Deputy Chair of the Advisory Council of the Australian National Preventive Health Agency and Chairs the Federal Minister's Men's Health Reference Group. He is on the GAVI Alliance Evaluation Advisory Committee and his University receives sitting fees. In a voluntary capacity, he chairs the Technical Advisory Panel to Avahan and is a member of the SEATCA Southeast Asia Initiative on Tobacco Tax (a project funded by the Gates Foundation) Steering Committee.</span></em></p>Australia spends more than $130 billion each year on health, approximately 9.2% of our GDP. The outcome of this and other investments is that our life expectancy puts us very high on the global “league…Rob Moodie, Professor of Global Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/136902013-04-30T20:04:55Z2013-04-30T20:04:55ZPhase out GP consultation fees for a better Medicare<figure><img src="https://images.theconversation.com/files/23046/original/yrcjtq87-1367299035.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The current fee-for-service model makes it difficult to contain costs and boost the quality of care.</span> <span class="attribution"><span class="source">Image from shutterstock.com</span></span></figcaption></figure><p><em>In the fourth part of our series <a href="https://theconversation.com/topics/health-rationing">Health Rationing</a>, Peter Sivey explains why it might be time to abandon Medicare’s fee-for-service model.</em></p>
<hr>
<p>Teachers aren’t paid a fee for each lesson they teach, nor are police officers paid for each arrest they make. Doctors, on the other hand, are paid for each patient they see. This funding model is the basis of Medicare, the main funder of out-of-hospital care across the country.</p>
<p>Medicare is largely a “fee-for-service” system. This has the benefits of simplicity and ease of administration: doctor sees patient, doctor collects fee. But the simplicity can also be a disadvantage for such a complex and multidimensional process as health care.</p>
<p>In 2010–11, Medicare Australia paid benefits of <a href="http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/1301.0%7E2012%7EMain%20Features%7EHealth%20care%20delivery%20and%20financing%7E235">A$16.4 billion</a> (up from A$10.9 billion in 2005-6), but taxation revenue from the Medicare Levy (including the Medicare Levy Surcharge) was only <a href="http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/1301.0%7E2012%7EMain%20Features%7EHealth%20care%20delivery%20and%20financing%7E235">A$8.3 billion</a>. So Medicare is a drain on government finances and there is increasing pressure to contain costs.</p>
<h2>Fee-for-service pitfalls</h2>
<p>The main issue with a fee-for-service system is defining what constitutes a “service”. For primary care, that usually means a level B consultation, where the GP sees the patient for up to 20 minutes. The GP receives <a href="http://www.health.gov.au/internet/mbsonline/publishing.nsf/Content/Factsheet-EMSN-1_Nov_2012_GP_Consultations">A$36.30 from Medicare</a> and can also charge the patient a co-payment. </p>
<p>This definition of a service automatically gives GPs incentives to see more patients and recommend follow-up appointments rather than provide long consultations to patients with multiple health conditions. </p>
<p>Anybody who’s been to an inner city 100% bulk-billing clinic will probably be familiar with what’s known as “six-minute medicine”. You barely sit down in the consulting room and tell the doctor what’s wrong before being ushered out, script or referral in hand. This phenomenon demonstrates the financial incentives of a fee-for-service system at its worst.</p>
<p>The dominance of fee-for-service medicine also inhibits team work in primary care, or task delegation, particularly between GPs and other health-care professionals such as nurses.</p>
<p>Practice nurses can play an important role in managing health conditions of the most complex and needy patients, such as those with diabetes or cancer. And employing more practice nurses can save expensive GPs from conducting routine vaccinations and cervical screening procedures. </p>
<p>But some GPs are reluctant to hire practice nurses, preferring to instead provide these services and receive the government rebates. As a result, Australia has just one practice nurse for every three GPs, compared with one nurse for every two GPs in the United Kingdom. </p>
<p>The fee-for-service system causes problems for both cost containment and quality of care – it’s certainly ripe for reform. </p>
<h2>A better alternative?</h2>
<p>The primary alternative to fee-for-service is capitation. This system involves paying doctors an annual fee for each patient they have enrolled in their practice. The payment is in return for the GP “looking after” that patient for the whole year. </p>
<p>So GPs do not receive more money for seeing their patients more often, and indeed will benefit from lower costs themselves if patient health improves and they require less care in the future.</p>
<p>Capitation has been the primary funding method for general practice in the United Kingdom for <a href="http://www.historyextra.com/feature/nhs-what-can-we-learn-history">more than 100 years</a>, and despite recent policy reforms to introduce performance payments, it remains the source of the majority of GPs’ revenue. </p>
<p>More recent examples of capitation come from North America. First is the growth of managed care in the United States, where capitation has been widely used, with the primary motivation of constraining costs. </p>
<p>A second example is in Canada, and <a href="http://www.cmaj.ca/content/181/10/668.short">the province of Ontario</a> in particular, where voluntary adoption of capitation by GPs has become increasingly popular over the past decade. Policymakers there see the main benefits of capitation as increased quality of care through team work and stable, controllable costs. </p>
<p>Sounds great so far? Well, there are some downsides. For capitation to work, patients have to be enrolled in only one practice - say goodbye to the convenience of visiting one doctor near your workplace and one near home. </p>
<p>Also, the annual payments need to be adjusted to meet the needs of enrolled populations (which means more capitation money for enrolling older, sicker patients).</p>
<h2>The road to reform</h2>
<p>While all health-care financing methods have disadvantages, to me the upsides of capitation outweigh the downsides. Having said that, a new payment system for doctors in Australia cannot be adopted overnight. </p>
<p>A voluntary scheme that gives GPs the option to enrol some patients and receive (initially small) capitation payments alongside their Medicare rebates, would be a good place to start. The fee-for-service system could be slowly phased out by freezing rebate levels so they become less valuable in real terms over time. Concurrently, capitation payments could be gradually increased to make them more attractive.</p>
<p>Capitation also has the advantage of working well alongside pay-for-performance schemes such as the <a href="https://theconversation.com/should-doctors-be-paid-to-keep-patients-healthy-3298">Quality and Outcomes Framework</a> in the UK. Indeed, the current <a href="https://www.dcp.org.au/public/index.cfm?action=showPublicContent&assetCategoryId=303">Diabetes Care Project</a> being run as a pilot scheme by the Australian Department of Health and Ageing, uses enrolment and capitation payments alongside performance pay to try and improve care for diabetes patients. </p>
<p>Perhaps the results of the trial will shed some light on the potential benefits of capitation payment for Australian GPs more widely. But we’ll have to wait – the project won’t begin its <a href="https://www.dcp.org.au/public/index.cfm?action=showPublicContent&assetCategoryId=307">evaluation phase</a> until early next year. </p>
<p><strong><em>This is the fourth part of our series <a href="https://theconversation.com/topics/health-rationing">Health Rationing</a>. Stay tuned for more articles in the lead up to the May budget or click on the links below:</em></strong></p>
<p><strong>Part one:</strong> <a href="https://theconversation.com/tough-choices-how-to-rein-in-australias-rising-health-bill-13658">Tough choices: how to rein in Australia’s rising health bill</a><br>
<strong>Part two:</strong> <a href="https://theconversation.com/explainer-what-is-health-rationing-13667">Explainer: what is health rationing?</a><br>
<strong>Part three:</strong> <a href="https://theconversation.com/a-conversation-that-promises-savings-worth-dying-for-13710">A conversation that promises savings worth dying for</a><br>
<strong>Part five:</strong> <a href="https://theconversation.com/focus-on-prevention-to-control-the-growing-health-budget-13665">Focus on prevention to control the growing health budget</a> </p><img src="https://counter.theconversation.com/content/13690/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Sivey receives funding from the Australian Research Council, National Health and Medical Research Council and the Victorian Department of Health.</span></em></p>In the fourth part of our series Health Rationing, Peter Sivey explains why it might be time to abandon Medicare’s fee-for-service model. Teachers aren’t paid a fee for each lesson they teach, nor are…Peter Sivey, Senior Research Fellow, Health Economics, Melbourne Institute of Applied Economic and Social Research, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/137102013-04-28T20:07:09Z2013-04-28T20:07:09ZA conversation that promises savings worth dying for<figure><img src="https://images.theconversation.com/files/22921/original/pndjgs4q-1366959342.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">We require the largest amount of health-care dollars in the last 30 days of our life.</span> <span class="attribution"><span class="source">Lee Haywood</span></span></figcaption></figure><p>On the eve of a federal budget looking for savings, I would like to report a medical intervention that reduces suffering, can prolong life and dramatically reduces health-care costs. The intervention itself costs nothing. But first, a story.</p>
<p>Jim was 78 when, on an empty road, he drove his car at 100 kilometres an hour into a tree. Maybe he’d had a minor stroke – he’d certainly had others due to vascular disease brought on by a lifetime of smoking. He was badly injured – limbs, pelvis, chest, intestines – and, on paper, had no chance of survival. His doctors had two options.</p>
<p>a) Talk to his family, establish any wishes or preferences Jim had expressed, assure them that he would receive the best of comfort measures and allow him to die in a quiet room.</p>
<p>b) Operate on all the fractures and ruptures, keep Jim on a ventilator in an intensive care unit for a month (during which time he would have more money spent on his health care than he had contributed in a lifetime via the Medicare Levy) and hope that he would beat the odds. </p>
<p>He didn’t. I know because we chose b. Or rather, in the absence of a conscious effort to choose anything, b just happened. In acute care (where Jim arrived after his accident), heroic management is the default setting.</p>
<p>This “do everything default” is a heady mix of historical, ethical and legal elements. It includes acting under the principle of necessity (the notion of “emergencies”), technical imperatives (a belief that because we have the technology we are obliged to use it in all cases) and medical imperatives. These are unnuanced notions of duty rooted in a parentalistic version of beneficence - medical ethics reduced to a bumper sticker.</p>
<p>It takes about one minute to treat a patient according to the standard default (admit-operate-ICU), and about two and a half hours to have a proper discussion with the medical teams, the patient and the family. It’s not surprising that the default generally wins out.</p>
<p>The truth is dying is not only scary but also scarily expensive. It’s widely known that the last year of our lives is when the most health-care dollars are spent. It’s less well-known that essentially all of this is <a href="https://www.mja.com.au/journal/2007/187/7/hospital-costs-older-people-new-south-wales-last-year-life">spent in the last 30 days</a> of someone’s life. </p>
<p>As in a war, it’s the last, futile battle that is the most costly, in a number of ways. Because the costs of dying come in many forms – financial, opportunity, emotional and physical, all borne variously by the individual, the family and society.</p>
<p>Though not all of us are destined to die like Jim, most Australians will <a href="https://www.mja.com.au/journal/2011/194/11/hospital-and-emergency-department-use-last-year-life-baseline-future">die in acute care hospitals</a>, and almost all will be <a href="http://www.publish.csiro.au/paper/AH11125.htm">suffering from chronic, incurable diseases</a>. Which is, of course, not a good fit for an acute care system founded on the duty to rescue and to cure at all costs. </p>
<p>This modern conundrum arose from the rapidly shifting demographic: as we die at an older age, so we die of relapsing chronic diseases. And each relapse results in an admission to an acute care hospital, where we ultimately die.</p>
<p>At the same time as this demographic shift, we have seen the rise of patient autonomy – all previous notions of “best interests” and “futility” now are largely resolved around establishing what the patient would have wanted. Talking to patients and their families, and taking into account their wishes is now an expected part of health care. </p>
<p>Before 1980, medicine largely revolved around a “doctor-knows-best” approach. The notion that decisions were to be negotiated with patients and their families started with a series of high-profile legal cases in the United States. The first “Do Not Resuscitate” orders appeared in the late 1970s, and the first mention of “informed consent” was in 1980.</p>
<p>Acute care hospitals are ill-prepared for this new role as the default place of death for the elderly; few have any systems in place to recognise the signs of dying early enough to have chance to provide palliation. Indeed, for two-thirds of the people receiving acute care, dying is only <a href="http://www.publish.csiro.au/paper/AH11125.htm">recognised on the last day of life</a>. Nor are attempts routinely made to establish what the wishes of the patient would have been. </p>
<p>There’s now abundant evidence to back up the extravagant claims I made at the start of this article – we can prove that talking to patients and their families <a href="http://www.bmj.com/content/340/bmj.c1345">reduces stress</a>, that dying outside an intensive care unit is <a href="http://www.ncbi.nlm.nih.gov/pubmed/21612730">cheaper and less painful</a>, that cancer patients managed palliatively may <a href="http://pallcare.ru/File/NEJMoa1000678.pdf">out-survive those treated more aggressively</a>, and that talking about death in advance is <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2862687/">associated with both</a> lower cost of dying and a better death.</p>
<p>So what is this is this marvellous, free medical intervention? Maybe you have guessed by now – it’s just having a conversation. A conversation that starts when you are in your final years, that asks about your goals, and about who would speak for you if (and when) you lost the capacity to speak for yourself. A conversation that continues through hospital admissions, where your doctors and nurses expect to work with you, as well as for you.</p>
<p>This conversation rarely happens without support. The success of the <a href="http://www.respectingpatientchoices.org.au/index.php?option=com_content&view=article&id=7&Itemid=8">Respecting Patient Choices</a> program, which takes a systematic approach to initiating this conversation in both acute and residential care, is due the way it trains people to introduce and continue this dialogue. </p>
<p>Clearly any conversation needs two sides. We need to understand that our deaths will not be with a bang but with a series of diminishing whimpers. We can all start now: ask yourself “who will speak for me when I can’t speak for myself?” Then “what do I need to say to this person?” The role of acute care is to systematically pick up this conversation, to routinely ask for this information, and to have ways to translate this into forms intelligible to the acute care system.</p>
<p>It’s the eve of a federal budget. You can almost hear the snap of the public purses closing all over Australia. There is a win–win out there, a conversation that can improve care and save an enormous amount of money. Can we afford silence?</p>
<p><strong><em>This is the third part of our series <a href="https://theconversation.com/topics/health-rationing">Health Rationing</a>. Stay tuned for more articles in the lead up to the May budget and click on the links below:</em></strong></p>
<p><strong>Part one:</strong> <a href="https://theconversation.com/tough-choices-how-to-rein-in-australias-rising-health-bill-13658">Tough choices: how to rein in Australia’s rising health bill</a><br> <strong>Part two:</strong> <a href="https://theconversation.com/explainer-what-is-health-rationing-13667">Explainer: what is health rationing?</a><br>
<strong>Part four:</strong> <a href="https://theconversation.com/phase-out-gp-consultation-fees-for-a-better-medicare-13690">Phase out GP consultation fees for a better Medicare</a><br>
<strong>Part five:</strong> <a href="https://theconversation.com/focus-on-prevention-to-control-the-growing-health-budget-13665">Focus on prevention to control the growing health budget</a></p><img src="https://counter.theconversation.com/content/13710/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Saul 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>On the eve of a federal budget looking for savings, I would like to report a medical intervention that reduces suffering, can prolong life and dramatically reduces health-care costs. The intervention itself…Peter Saul, Senior Specialist in Intensive Care and Head of Clinical Unit in Ethics and Health Law, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/136672013-04-24T04:31:16Z2013-04-24T04:31:16ZExplainer: what is health rationing?<figure><img src="https://images.theconversation.com/files/22780/original/87ssgs32-1366688517.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">We need a more rational debate about how and where we spend our finite health budget.</span> <span class="attribution"><span class="source">Image from shutterstock.com</span></span></figcaption></figure><p><em><a href="https://theconversation.com/topics/health-rationing">HEALTH RATIONING</a> – a series which examines Australia’s rising health costs and the tough decisions governments must make to rein them it.</em> </p>
<hr>
<p>Any mention of the “R” word in health care <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1203521">immediately brings to mind</a> cuts to services and not being able to access care. It also conjures images of penny-pinching bureaucrats, managers and accountants who have nothing better to do but crack the fiscal whip. </p>
<p>Politicians publicly avoid the “R” word if they can; while doctors fight to retain the autonomy associated with doing “the best” for their patients regardless of the cost.</p>
<p>There’s no doubt the rationing debate needs to become more rational. Let’s start with the basics of health rationing.</p>
<h2>1. Rationing happens all the time</h2>
<p>With a finite budget, rationing in health care occurs every day. Every decision a doctor makes, such as whether to prescribe a drug, order a test, make a referral, undertake an operation, practice in a rural or urban area, is a rationing decision. Why? Because they are using scarce (often taxpayer-funded) resources that could, if used on someone else, lead to a greater improvement in health and well-being. </p>
<p>Other decision-makers such as politicians, bureaucrats and health-care managers who make broader decisions about which services are funded and which services are not funded also ration health care. This type of rationing is implicit: it’s done behind closed doors and tends to be based more on lobbying than good science and research evidence.</p>
<h2>2. Government bodies ration health care</h2>
<p>Explicit rationing involves deliberation and judgements about the cost-effectiveness of new pharmaceuticals, medical technologies and other health interventions. </p>
<p>For medicines, Australia’s <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/Pharmaceutical+Benefits+Advisory+Committee-1">Pharmaceutical Benefits Advisory Committee</a> (PBAC) advises which drugs are cost-effective and therefore should be subsidised by government. If a decision is made not to fund a high-cost cancer drug from the <a href="http://www.pbs.gov.au/pbs/home">Pharmaceutical Benefits Scheme</a>, for instance, PBAC is effectively saying the resources that would be used to fund the drug could be better used - that is, provide more health improvements - for something else. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/22804/original/ywkbgywh-1366703810.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/22804/original/ywkbgywh-1366703810.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/22804/original/ywkbgywh-1366703810.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/22804/original/ywkbgywh-1366703810.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/22804/original/ywkbgywh-1366703810.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/22804/original/ywkbgywh-1366703810.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/22804/original/ywkbgywh-1366703810.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">
<figcaption>
<span class="caption">PBAC rations pharmaceuticals.</span>
<span class="attribution"><span class="source">Image from shutterstock.com</span></span>
</figcaption>
</figure>
<p>These types of decisions do, of course, mean that some people lose out but others gain. </p>
<p>For medical interventions, the <a href="http://www.msac.gov.au/">Medical Services Advisory Committee</a> (MSAC) decides which treatments should be funded under Medicare. This includes new pathology and diagnostic tests, new surgical procedures, as well as reviewing old technologies.</p>
<p>Other countries also have these explicit rationing mechanisms, such as the <a href="http://www.nice.org.uk/">National Institute of Health and Care Excellence</a> (NICE) in the United Kingdom. </p>
<h2>3. Rationing, if based on good evidence, can save lives</h2>
<p>Doctors and decision makers rely on their considerable experience and training to make decisions about the most worthwhile and valuable interventions to provide. But in some circumstances, doctors’ knowledge can become out of date as evidence on the cost-effectiveness of new technologies and better ways of doing things become available. </p>
<p>Prescribing antibiotics for the common cold is now <a href="http://www.nps.org.au/medicines/infections-and-infestations/antibiotic-medicines/antibiotics-for-respiratory-tract-infections/for-individuals/how-do-i-take-my-antibiotics/antibiotics-dont-kill-viruses">regarded as ineffective</a>, for instance, yet some doctors still write these prescriptions. And it has taken many years for the rates of such prescribing to fall. </p>
<p>Rationing without information on the costs and benefits of health-care interventions can lead to waste, inefficiency and even loss of life.</p>
<p>So what’s the solution? It won’t be easy; improving the uptake of new evidence should include changes to <a href="https://theconversation.com/should-doctors-be-paid-to-keep-patients-healthy-3298">funding and incentives</a>, as part of a multi-faceted approach. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/22803/original/t4qm488t-1366703685.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/22803/original/t4qm488t-1366703685.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=371&fit=crop&dpr=1 600w, https://images.theconversation.com/files/22803/original/t4qm488t-1366703685.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=371&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/22803/original/t4qm488t-1366703685.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=371&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/22803/original/t4qm488t-1366703685.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=466&fit=crop&dpr=1 754w, https://images.theconversation.com/files/22803/original/t4qm488t-1366703685.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=466&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/22803/original/t4qm488t-1366703685.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=466&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There are many procedures, drugs and treatments that are embedded in routine clinical but provide no or little benefit to patients.</span>
<span class="attribution"><span class="source">Image from shutterstock.com</span></span>
</figcaption>
</figure>
<h2>Rationing or choosing wisely?</h2>
<p>The rhetoric about rationing is just as extreme in the United States as it is in Australia. But this is being tackled intelligently by the medical profession by using less emotive language, such as “<a href="http://www.choosingwisely.org/about-us/">choosing wisely</a>”. </p>
<p>There is <a href="http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2202879">recognition</a> that many health-care treatments are being provided that are of little value. This includes diagnostic technologies that lead to <a href="https://theconversation.com/topics/overdiagnosis">over-diagnosis</a> – diagnoses for which there is no effective treatment or which have little impact on people’s lives. The benefits of new technologies are often overemphasised so they suck up valuable resources that could be used to save lives now. </p>
<p><a href="https://theconversation.com/psa-screening-and-prostate-cancer-over-diagnosis-8568">PSA testing</a> for prostate cancer is an example of a treatment that may do more harm than good.</p>
<p>There are also procedures, drugs and treatments that might be heavily promoted by drug companies which benefit financially, or might be embedded in routine clinical care, but for which evidence shows that there are no or little benefits to health status or well-being. These are the low hanging fruit of rationing – the “no brainers” - where stopping the provision of these treatments could <a href="http://jama.jamanetwork.com/article.aspx?articleid=1148376">potentially save</a> tens of millions of dollars that can be used to save lives in other areas.</p>
<p>So there is some hope and optimism that re-framing the debate about rationing may lead to a more rational discussion on how to allocate health-care resources in better ways to save more lives. But to work, this debate needs to be led by the medical profession and supported by government. Decision-makers and doctors need to seriously consider how doing less is doing more.</p>
<p><strong><em>This is the second part of our series <a href="https://theconversation.com/topics/health-rationing">Health Rationing</a>. Stay tuned for more articles in the lead up to the May budget or click on the links below:</em></strong></p>
<p><strong>Part one:</strong> <a href="https://theconversation.com/tough-choices-how-to-rein-in-australias-rising-health-bill-13658">Tough choices: how to rein in Australia’s rising health bill</a><br>
<strong>Part three:</strong> <a href="https://theconversation.com/a-conversation-that-promises-savings-worth-dying-for-13710">A conversation that promises savings worth dying for</a><br>
<strong>Part four:</strong> <a href="https://theconversation.com/phase-out-gp-consultation-fees-for-a-better-medicare-13690">Phase out GP consultation fees for a better Medicare</a><br>
<strong>Part five:</strong> <a href="https://theconversation.com/focus-on-prevention-to-control-the-growing-health-budget-13665">Focus on prevention to control the growing health budget</a></p><img src="https://counter.theconversation.com/content/13667/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Scott receives funding from the ARC, NHMRC, and Victorian Department of Health.</span></em></p>HEALTH RATIONING – a series which examines Australia’s rising health costs and the tough decisions governments must make to rein them it. Any mention of the “R” word in health care immediately brings to…Anthony Scott, Professorial Fellow & ARC Future Fellow, Melbourne Institute of Applied Economic and Social Research, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/136582013-04-24T04:31:14Z2013-04-24T04:31:14ZTough choices: how to rein in Australia’s rising health bill<figure><img src="https://images.theconversation.com/files/22802/original/mzsyw4qp-1366703553.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The biggest and fastest-growing spending category in health is hospitals.</span> <span class="attribution"><span class="source">Image from shutterstock.com</span></span></figcaption></figure><p><em>With health costs rising and costly medical innovations on the horizon, it’s crunch time for health funding. In the lead up to the May budget, The Conversation’s experts will explore the options for reining in costs – but warn governments must make some tough decisions.</em> </p>
<hr>
<p>Health spending is eating up more and more of government budgets, both state and federal. In fact, government health spending grew 74% over the past decade, far faster than GDP, which grew by 46% above CPI.</p>
<p>Health spending started from a large base too. Australian governments are spending almost A$42 billion more this year in real terms on health than they did a decade ago, compared to A$28 billion more on welfare and A$22 billion more on education.</p>
<p>For government budgets, health is a big deal and getting bigger. Grattan Institute’s new report, <a href="http://grattan.edu.au/static/files/assets/f2ac486a/187_budget_pressures_report.pdf">Budget Pressures on Australian Governments</a> shows that health expenses are 19% of Australian government budgets (state and federal), compared to 17% in 2002 to 03.</p>
<p>Although all categories of government health spending are growing, some are growing faster than others. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/22774/original/k69hm4bv-1366684362.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/22774/original/k69hm4bv-1366684362.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/22774/original/k69hm4bv-1366684362.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=415&fit=crop&dpr=1 600w, https://images.theconversation.com/files/22774/original/k69hm4bv-1366684362.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=415&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/22774/original/k69hm4bv-1366684362.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=415&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/22774/original/k69hm4bv-1366684362.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=522&fit=crop&dpr=1 754w, https://images.theconversation.com/files/22774/original/k69hm4bv-1366684362.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=522&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/22774/original/k69hm4bv-1366684362.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=522&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Change in total government health payment expenditure by sub-category, 2002-3 to 2012-13, % change above CPI.</span>
<span class="attribution"><span class="source">Grattan Institute</span></span>
</figcaption>
</figure>
<p>The biggest and fastest-growing spending category in health is hospitals – they get almost A$18 billion in real terms more than in 2002-03, an increase of over 95%. </p>
<p>The next biggest category is primary care and medical services, which includes Medicare. It has grown by over 60%, accounting for a further A$11 billion increase. </p>
<p>Other areas of health, such as pharmaceuticals and subsidies for private health insurance, have grown substantially but off much smaller bases.</p>
<h2>Why are health costs rising?</h2>
<p>Received wisdom is that rising health costs are all about demographic change, but this is not true. Together, population growth and the ageing population structure accounted for only a quarter of government expenditure growth above CPI since 2002-2003. A further 5% of the growth comes from health inflation growing faster than CPI.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/22775/original/qhft9rrz-1366684362.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/22775/original/qhft9rrz-1366684362.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/22775/original/qhft9rrz-1366684362.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=414&fit=crop&dpr=1 600w, https://images.theconversation.com/files/22775/original/qhft9rrz-1366684362.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=414&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/22775/original/qhft9rrz-1366684362.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=414&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/22775/original/qhft9rrz-1366684362.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=520&fit=crop&dpr=1 754w, https://images.theconversation.com/files/22775/original/qhft9rrz-1366684362.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=520&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/22775/original/qhft9rrz-1366684362.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=520&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Drivers of change in government health expenditure, 2002-03 to 2012-13 (A$bn in real terms).</span>
<span class="attribution"><span class="source">Grattan Institute</span></span>
</figcaption>
</figure>
<p>The rest of the increase is due to people of all ages getting more and more expensive services per person. On average, a 50-year-old now is seeing doctors more often, having more tests and operations, and taking more prescription drugs, than a 50-year-old did ten years ago. The quality of the treatment they are getting has improved in many cases, and there are new treatments that did not exist in 2003.</p>
<p>There’s no reason to think that this trend will slow down in the next ten years without major policy reform. Government health spending now consumes an additional 1% of GDP compared to a decade ago; this is projected to increase to 2% in the next ten years.</p>
<h2>Both costs and benefits</h2>
<p>Spending more on health is not necessarily a bad thing – in fact, it’s exactly what you would expect an advanced, prosperous economy to do. The [international evidence shows](http://www.oecd.org/els/health-systems/49105858.pdf](http://www.oecd.org/els/health-systems/49105858.pdf) that as economies grow, so too does health spending. </p>
<p>We can treat all sorts of conditions more effectively now than we used to, and it’s having an impact. Life expectancy for those aged 65 has been rising rapidly since 1970. Death rates from conditions where health care <a href="http://www.publichealth.gov.au/data/atlas-of-avoidable-mortality_-australia.html">might make a difference</a> are going down.</p>
<p>But someone is going to have to pay for the better treatment that benefits us all. Tough policy choices will need to be made to either increase government revenues, or keep a lid on costs.</p>
<h2>How to reduce health spending</h2>
<p>Reducing health spending growth will not be easy. As Grattan’s <a href="http://grattan.edu.au/publications/reports/post/game-changers-supporting-materials/">Game-changers report</a> last year showed, Australia already has one of the OECD’s most efficient health systems, in terms of life expectancy achieved for dollars spent. </p>
<p>Sweeping cuts to health funding, or shifting costs to consumers, could have serious consequences. Blunt cost-cutting risks reducing health and well-being, and could ultimately lead to higher government costs due to illness, increased health-care needs and lower workforce participation.</p>
<p>But not every dollar we spend on health care is well spent and the best way to start is by focusing on efficiency. One area we do know that there’s room for improvement is pharmaceuticals. As Grattan’s report <a href="http://grattan.edu.au/publications/reports/post/australias-bad-drug-deal/">Australia’s Bad Drug Deal</a> shows, Australia’s Pharmaceutical Benefits Scheme pays at least A$1.3 billion a year too much for prescription drugs. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/22805/original/q6qfw3hy-1366704375.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/22805/original/q6qfw3hy-1366704375.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/22805/original/q6qfw3hy-1366704375.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/22805/original/q6qfw3hy-1366704375.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/22805/original/q6qfw3hy-1366704375.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/22805/original/q6qfw3hy-1366704375.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/22805/original/q6qfw3hy-1366704375.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Australia wastes A$1.3 billion a year on overpriced drugs.</span>
<span class="attribution"><span class="source">Image from shutterstock.com</span></span>
</figcaption>
</figure>
<p>There are real savings to be made from reforming our drug purchase process, bargaining harder on generic drug prices, and encouraging drug substitutions.</p>
<p>In terms of hospital efficiency, which varies greatly across the country, governments have agreed to introduce a new funding formula, based on paying for <a href="http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/nhra-brief-qa-abf#.UXZDxytdNHg">hospital activity</a> using a “national efficient price”. This is a good first step to reduce waste, but there is more room for reform. </p>
<p>Under current public hospital funding arrangements, the “national efficient price” pays extra for complex patients, regardless of whether the complexity is caused by things that happened after the patient was admitted or whether they arrived at the hospital in that condition. Why do we still pay more to hospitals which have higher rates of mistakes or mishaps? </p>
<p>Getting rid of waste sounds easy, but every dollar of health spending is someone’s dollar of income, and there are plenty of vested interests who want to keep their revenue stream.</p>
<p>Of course, not all health spending is waste, not by a long shot. But even if we make tough choices about waste, we might still be left with the next choice. Do we want to put our hands in our pockets to fund more health care with increased taxes, or will something else have to give?</p>
<p><strong><em>This is the first part of our series <a href="https://theconversation.com/topics/health-rationing">Health Rationing</a>. Stay tuned for more articles in the lead up to the May budget and click on the links below:</em></strong></p>
<p><strong>Part two:</strong> <a href="https://theconversation.com/explainer-what-is-health-rationing-13667">Explainer: what is health rationing?</a><br>
<strong>Part three:</strong> <a href="https://theconversation.com/a-conversation-that-promises-savings-worth-dying-for-13710">A conversation that promises savings worth dying for</a><br>
<strong>Part four:</strong> <a href="https://theconversation.com/phase-out-gp-consultation-fees-for-a-better-medicare-13690">Phase out GP consultation fees for a better Medicare</a><br>
<strong>Part five:</strong> <a href="https://theconversation.com/focus-on-prevention-to-control-the-growing-health-budget-13665">Focus on prevention to control the growing health budget</a></p><img src="https://counter.theconversation.com/content/13658/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>With health costs rising and costly medical innovations on the horizon, it’s crunch time for health funding. In the lead up to the May budget, The Conversation’s experts will explore the options for reining…Stephen Duckett, Director, Health Program, Grattan InstituteCassie McGannon, Senior Associate, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/94962012-09-19T01:37:35Z2012-09-19T01:37:35ZSix easy ways to improve health services<figure><img src="https://images.theconversation.com/files/15616/original/3yzy287k-1347948207.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Health services are ripe for evidence-based reform.</span> <span class="attribution"><span class="source">www.shutterstock.com</span></span></figcaption></figure><p>Each year <a href="http://www.aihw.gov.au/publication-detail/?id=10737420435&tab=2">$120 billion is spent</a> on health services in Australia. But hardly any research is done to investigate whether this money is being used wisely. </p>
<p>Only 2.8% of the funding <a href="http://www.nhmrc.gov.au/grants/outcomes-funding-rounds/previous-outcomes-project-grants-funding-rounds">for NHMRC project grants</a> was devoted to health services research projects in 2011. </p>
<p>Today’s climate of financial austerity means we must find ways to save costs and improve health outcomes by investing in the best possible organisation of health services. We know we can’t afford to provide every service we’d like and that some configurations of services are superior.</p>
<h2>Some alternatives</h2>
<p>Here are six examples of how to make changes to health services that save costs and increase health outcomes:</p>
<ol>
<li><p>Investing in good hospital discharge planning for high-risk elderly patients would save $333 million a year and would improve health outcomes. Research shows elderly patients who receive nursing and physiotherapy assessment via an individually tailored program of exercise strategies, and are followed-up for 24 weeks after discharge made <a href="http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0007455">fewer emergency re-admissions</a> and avoided many other health-care costs.</p></li>
<li><p>Paying less for generic drugs to lower cholesterol would have saved the Australian government <a href="https://www.mja.com.au/journal/2012/196/3/challenges-and-opportunities-pharmaceutical-benefits-scheme">$130 million</a> between May 2010 and October 2011. These large cost savings could be achieved if drug prices were negotiated to the level paid by the UK government for statins. </p></li>
<li><p>Stopping routine follow-up for <a href="http://www.crd.york.ac.uk/CRDWeb/ShowRecord.asp?ID=22010000617">patients with hip replacements</a> will save resources worth $9 million each year. In most cases, the only benefit is to reassure patients. If a meaningful complication arises, patients would seek health services regardless of any routine follow-up from their surgeon.</p></li>
<li><p>Using antimicrobial-coated catheters in ICU patients to reduce rates of infections will save $130 per catheter placed and generate health benefits. With 17% of the annual 120,000 ICU admissions likely to receive a catheter, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689469/">the cost savings</a> are $2.65 million a year. And dangerous infections are reduced, saving lives.</p></li>
<li><p>Stopping the use of <a href="http://www.unispital-basel.ch/fileadmin/unispitalbaselch/Bereiche/Medizin/Infektiologie_Spitalhygiene/Journal_Club/JC_pdf_File_Evelin_Bucheli_-_8.2.2012.pdf">laminar airflow</a> in operating theatres. The risk of <a href="http://www.nzoa.org.nz/content/Ten%20Year%20Report.pdf">costly and dangerous infections</a> increase with their use, and these systems cost money to install and maintain. Not having laminar air flow in Australian operating theatres will save at least $4.5 million each year and will generate health benefits from avoided infection.</p></li>
<li><p>Restricting the use of leucodepleted blood products. In 2008, Australian governments started paying for high-cost leucodepleted products for <a href="http://eprints.qut.edu.au/38528/">all blood transfusions</a>. This increased spending by $61 million a year and only delivered an extra 153 extra years of life. It’s not good value for money.</p></li>
</ol>
<figure><table><thead><tr><th>Proposed Change</th><th>Costs Saved</th><th>Health Benefits gained/lost</th></tr></thead><tbody><tr><td><a href="http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0007455">discharge planning</a></td><td>$333,000,000</td><td>118,000 extra QALYs</td></tr><tr><td><a href="https://www.mja.com.au/journal/2012/196/3/challenges-and-opportunities-pharmaceutical-benefits-scheme">pay less for drugs</a></td><td>$130,000,000</td><td>Zero</td></tr><tr><td><a href="http://www.crd.york.ac.uk/CRDWeb/ShowRecord.asp?ID=22010000617">follow up of hip replacement</a></td><td>$9,126,521</td><td>88 extra QALYs</td></tr><tr><td><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689469/">antimicrobial coated catheters</a></td><td>$2,657,896</td><td>34 extra QALYs</td></tr><tr><td><a href="http://www.nzoa.org.nz/content/Ten%20Year%20Report.pdf">laminar air flow</a></td><td>$4,592,200</td><td>127 extra QALYs</td></tr><tr><td><a href="http://eprints.qut.edu.au/38528/">leucodepleted blood</a></td><td>$61,000,000</td><td>153 fewer years of life</td></tr><tr><td><b>Total</b></td><td><b>$540,376,617</b></td><td><b>118,096</b></td></tr></tbody></table></figure>
<p>Making these changes would generate health benefits of 118,096 quality adjusted life years (QALY) and release resources worth $540 million for alternate use. If this money is redirected toward the <a href="http://www.resource-allocation.com/content/6/1/9">treatment interventions</a> found to cost only $14,161 per QALY gained, an extra 38,160 quality adjusted life years would result. In total, 156,256 extra quality adjusted life years (118,096 plus 38,160) would be enjoyed by Australians for no extra cost. All this arises from re-organising the health services that are already supplied.</p>
<h2>What to do?</h2>
<p>This pithy analysis has ignored the complexity of health-care decisions. In health care, those who allocate spending tend to be risk averse and fear media attacks over controversial decisions, even if the decision is the right thing to do for society. Ultimately, they may consider doing nothing as the safe option, even though it is grossly inefficient.</p>
<p>We recognise that cost-effectiveness is an important criterion, but many other factors play a role in decisions to invest or disinvest in services and technologies. These include uncertainty about the safety of making a change and the <a href="http://www.buseco.monash.edu.au/centres/che/pubs/wp89.pdf">availability of alternate interventions</a>; and fairness and equity of access to health services, and perceived need in the community. </p>
<p>One example is the high cost and small health benefit of providing emergency helicopter services for rural and remote communities. Although unlikely to be a cost-effective health service, it would be unfair not to help these communities when they needed it. Good health decisions balance efficiency and fairness.</p>
<p>Australian governments seek to improve productivity. Health services are ripe for evidence-based reform and data to support this are valuable. The <a href="http://www.aushsi.org.au/">Australian Centre for Health Services Innovation</a> is building partnerships with health-care professionals and academics to generate research evidence to improve health services. We hope senior health decision makers are motivated and excited by the work of AusHSI and will make strong health policy based on the evidence presented.</p>
<p><em>The disclosure statement on this article has been changed to reflect the fact that Professor Graves is the Academic Director of Australian Centre for Health Services Innovation.</em></p><img src="https://counter.theconversation.com/content/9496/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicholas Graves receives funding from ARC, NHMRC, NIHR, QLD Government. He is the academic director of the Australian Centre for Health Services Innovation.</span></em></p>Each year $120 billion is spent on health services in Australia. But hardly any research is done to investigate whether this money is being used wisely. Only 2.8% of the funding for NHMRC project grants…Nicholas Graves, Professor of Health Economics, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.