tag:theconversation.com,2011:/uk/topics/medicare-1897/articlesMedicare – The Conversation2024-03-18T14:31:13Ztag:theconversation.com,2011:article/2259542024-03-18T14:31:13Z2024-03-18T14:31:13ZProfits over patients: For-profit nursing home chains are draining resources from care while shifting huge sums to owners’ pockets<figure><img src="https://images.theconversation.com/files/582294/original/file-20240315-20-7m2n83.jpg?ixlib=rb-1.1.0&rect=0%2C17%2C6000%2C3907&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The for-profit nursing home sector is growing, and it places a premium on cost cutting and big profits, which has led to low staffing and patient neglect and mistreatment.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/february-2024-baden-w%C3%BCrttemberg-na-a-resident-of-a-nursing-news-photo/1985540302">picture alliance via Getty Images</a></span></figcaption></figure><p>The care at Landmark of Louisville Rehabilitation and Nursing was abysmal when state inspectors filed their survey report of the Kentucky facility on July 3, 2021.</p>
<p>Residents <a href="https://www.documentcloud.org/documents/24170104-landmark-nursing-070321#document/p72/a2407365">wandered the halls</a> in a facility that can house up to 250 people, yelling at each other and stealing blankets. One resident beat a roommate <a href="https://www.documentcloud.org/documents/24170104-landmark-nursing-070321#document/p66/a2407364">with a stick</a>, causing bruising and skin tears. Another was found in bed with a broken finger and a bloody forehead <a href="https://www.documentcloud.org/documents/24170104-landmark-nursing-070321#document/p55/a2407366">gash</a>. That person was allowed to roam and enter the beds of other residents. In another case, there was <a href="https://www.documentcloud.org/documents/24170104-landmark-nursing-070321#document/p21/a2407367">sexual touching</a> in the dayroom between residents, according to the report.</p>
<p>Meals were served from filthy meal carts on plastic foam trays, and residents struggled to cut their food with dull plastic cutlery. Broken tiles lined showers, and a mysterious black gunk marred the floors. The director of housekeeping reported that the dining room was unsanitary. Overall, there was a critical lack of training, staff and <a href="https://projects.propublica.org/nursing-homes/homes/h-185122">supervision</a>.</p>
<p>The inspectors tagged Landmark as <a href="https://medicare.gov/care-compare/inspections/pdf/nursing-home/185122/health/standard?date=2021-07-03">deficient in 29 areas</a>, including six that put residents in immediate jeopardy of serious harm and three where actual harm was found. The issues were so severe that the government slapped Landmark with <a href="https://www.medicare.gov/care-compare/details/nursing-home/185122?state=KY&measure=nursing-home-penalties">a fine of over US$319,000</a> − <a href="https://data.cms.gov/provider-data/dataset/g6vv-u9sr">more than 29 times the average</a> for a nursing home in 2021 − and suspended payments to the home from federal Medicaid and Medicare funds. </p>
<p>But problems persisted. Five months later, inspectors levied six additional deficiencies of immediate jeopardy − the highest level.</p>
<p>Landmark is just one of the 58 facilities run by parent company Infinity Healthcare Management across five states. The government issued penalties to the company almost 4½ times the national average, according to bimonthly data that the Centers for Medicare & Medicaid Services first started to make available in late 2022. All told, Infinity paid <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">nearly $10 million in fines</a> since 2021, the highest among nursing home chains with fewer than 100 facilities.</p>
<p>Infinity Healthcare Management and its executives did not respond to multiple requests for comment.</p>
<h2>Race to the bottom</h2>
<p>Such <a href="https://violationtracker.goodjobsfirst.org/">sanctions are nothing new</a> for Infinity or other for-profit nursing home chains that have dominated an industry long known for cutting corners in pursuit of profits for private owners. But this race to the bottom to extract profits is accelerating, despite demands by <a href="https://www.gao.gov/assets/gao-23-104813.pdf">government officials</a>, health care experts and advocacy groups to protect the nation’s most vulnerable citizens.</p>
<p>To uncover the reasons why, The Conversation delved into the nursing home industry, where for-profit facilities make up more than 72% of the nation’s nearly 14,900 facilities. The probe, which paired an academic expert with an investigative reporter, used the most recent government data on ownership, facility information and penalties, combined with <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">CMS data on affiliated entities</a> for nursing homes.</p>
<p>The investigation revealed an industry that places a premium on cost cutting and big profits, with low staffing and poor quality, often to the detriment of patient well-being. Operating under <a href="https://dx.doi.org/10.2139/ssrn.4541739">weak and poorly enforced regulations</a> with financially insignificant penalties, the for-profit sector fosters an environment where corners are frequently cut, compromising the quality of care and endangering patient health. </p>
<p>Meanwhile, owners make the facilities look less profitable by siphoning money from the homes through byzantine networks of interconnected corporations. Federal regulators have neglected the problem as <a href="https://theconsumervoice.org/news/detail/latest/new-report-nursing-homes-funnel-dollars-through-related-party-companies">each year likely billions of dollars are funneled</a> out of nursing homes through related parties and into owners’ pockets.</p>
<h2>More trouble at midsize</h2>
<p>Analyzing <a href="https://data.cms.gov/search">newly released government data</a>, our investigation found that these problems are most pronounced in nursing homes like Infinity − midsize chains that <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">operate between 11 and 100 facilities</a>. This subsection of the industry has higher average fines per home, lower overall quality ratings, and are more likely to be tagged with resident abuse compared with both the larger and smaller networks. Indeed, while such chains account for about 39% of all facilities, they operate 11 of the 15 most-fined facilities.</p>
<p><iframe id="DRwGq" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/DRwGq/6/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>With few impediments, private investors who own the midsize chains have swooped in to purchase underperforming homes, expanding their holdings even as larger chains divest and close facilities.</p>
<p>“They are really bad, but the names − we don’t know these names,” said Toby Edelman, senior policy attorney with the Center for Medicare Advocacy, a nonprofit law organization.</p>
<p>In response to The Conversation’s findings on nursing homes and request for an interview, a CMS spokesperson emailed <a href="https://www.documentcloud.org/documents/24478510-nursing-home-information-request">a statement</a> that said the CMS is “unwavering in its commitment to improve safety and quality of care for the more than 1.2 million residents receiving care in Medicare- and Medicaid-certified nursing homes.”</p>
<p>“We support transparency and accountability,” the American Health Care Association/National Center for Assisted Living, a trade organization representing the nursing home industry, <a href="https://www.documentcloud.org/documents/24475011-re-nursing-home-chains-and-cms-regulation-the-conversation-deadline-34-at-5pm-est">wrote in response</a> to The Conversation‘s request for comment. “But neither ownership nor line items on a budget sheet prove whether a nursing home is committed to its residents.”</p>
<h2>Ripe for abuse</h2>
<p>It often takes years to improve a poor nursing home − or <a href="https://www.newyorker.com/news/dispatch/when-private-equity-takes-over-a-nursing-home">run one into the ground</a>. The analysis of midsize chains shows that most owners have been associated with their current facilities for less than eight years, making it difficult to separate operators who have taken long-term investments in resident care from those who are looking to quickly extract money and resources <a href="https://www.wpr.org/st-louis-nursing-home-closes-suddenly-prompting-wider-concerns-over-care">before closing them down or moving on</a>. These chains control roughly 41% of nursing home beds in the U.S., according to CMS’s provider data, making the lack of transparency especially ripe for abuse.</p>
<p>A churn of nursing home purchases even during the pandemic shows that investors view the sector as <a href="https://doi.org/10.1111/jgs.17288">highly profitable</a>, especially when staffing costs are kept low and fines for poor care can easily be covered by the money extracted from residents, their families and taxpayers.</p>
<p>A March 2024 study from Lehigh University and the University of California, Los Angeles also <a href="https://ucla.app.box.com/v/RelatedParties">shows that costs were inflated</a> when nursing home owners switched to contractors they controlled directly or indirectly. Overall, spending on real estate increased 20.4% and spending on management increased 24.6% when the businesses were affiliated, the research showed.</p>
<p>“This is the model of their care: They come in, they understaff and they make their money,” said Sam Brooks, director of public policy at the Consumer Voice, a national resident advocacy organization. “Then they multiply it over a series of different facilities.”</p>
<p><em>This is a condensed version of an article from The Conversation’s <a href="https://theconversation.com/announcing-the-conversations-new-investigative-unit-were-looking-for-collaborators-in-academia-207394">investigative unit</a>. To find out more about the rise of for-profit nursing homes, financial trickery and what could make the nation’s most vulnerable citizens safer, <a href="https://theconversation.com/for-profit-nursing-homes-are-cutting-corners-on-safety-and-draining-resources-with-financial-shenanigans-especially-at-midsize-chains-that-dodge-public-scrutiny-225045">read the complete version</a>.</em></p><img src="https://counter.theconversation.com/content/225954/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Campbell is an adjunct assistant professor at Columbia University and a contributing writer at the Garrison Project, an independent news organization that focuses on mass incarceration and criminal justice.</span></em></p><p class="fine-print"><em><span>Harrington is an advisory board member of the nonprofit Veteran's Health Policy Institute and a board member of the nonprofit Center for Health Information and Policy. Harrington served as an expert witness on nursing home litigation cases by residents against facilities owned or operated by Brius and Shlomo Rechnitz in the past and in 2022. She also served as an expert witness in a case against The Citadel Salisbury in North Carolina in 2021. </span></em></p>Owners of midsize nursing home chains harm the elderly and drain huge sums of money from facilities using opaque accounting practices while government doesn’t do enough to stop it.Sean Campbell, Investigative journalist, The ConversationCharlene Harrington, Professor Emeritus of Social Behavioral Sciences, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2250452024-03-14T12:46:59Z2024-03-14T12:46:59ZFor-profit nursing homes are cutting corners on safety and draining resources with financial shenanigans − especially at midsize chains that dodge public scrutiny<figure><img src="https://images.theconversation.com/files/580044/original/file-20240306-22-la93ja.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5982%2C3988&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The for-profit nursing home sector is growing, while placing a premium on cost cutting and big profits.</span> <span class="attribution"><span class="source">picture alliance via Getty Images</span></span></figcaption></figure><p>The care at Landmark of Louisville Rehabilitation and Nursing was abysmal when state inspectors filed their survey report of the Kentucky facility on July 3, 2021.</p>
<p>Residents <a href="https://www.documentcloud.org/documents/24170104-landmark-nursing-070321#document/p72/a2407365">wandered the halls</a> in a facility that can house up to 250 people, yelling at each other and stealing blankets. One resident beat a roommate <a href="https://www.documentcloud.org/documents/24170104-landmark-nursing-070321#document/p66/a2407364">with a stick</a>, causing bruising and skin tears. Another was found in bed with a broken finger and a bloody forehead <a href="https://www.documentcloud.org/documents/24170104-landmark-nursing-070321#document/p55/a2407366">gash</a>. That person was allowed to roam and enter the beds of other residents. In another case, there was <a href="https://www.documentcloud.org/documents/24170104-landmark-nursing-070321#document/p21/a2407367">sexual touching</a> in the dayroom between residents, according to the report.</p>
<p>Meals were served from filthy meal carts on plastic foam trays, and residents struggled to cut their food with dull plastic cutlery. Broken tiles lined showers, and a mysterious black gunk marred the floors. The director of housekeeping reported that the dining room was unsanitary. Overall, there was a critical lack of training, staff and <a href="https://projects.propublica.org/nursing-homes/homes/h-185122">supervision</a>.</p>
<p>The inspectors tagged Landmark as <a href="https://medicare.gov/care-compare/inspections/pdf/nursing-home/185122/health/standard?date=2021-07-03">deficient in 29 areas</a>, including six that put residents in immediate jeopardy of serious harm and three where actual harm was found. The issues were so severe that the government slapped Landmark with <a href="https://www.medicare.gov/care-compare/details/nursing-home/185122?state=KY&measure=nursing-home-penalties">a fine of over US$319,000</a> − <a href="https://data.cms.gov/provider-data/dataset/g6vv-u9sr">more than 29 times the average</a> for a nursing home in 2021 − and suspended payments to the home from federal Medicaid and Medicare funds.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/580527/original/file-20240307-28-o5dqjy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Highlighted excerpt from a report" src="https://images.theconversation.com/files/580527/original/file-20240307-28-o5dqjy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/580527/original/file-20240307-28-o5dqjy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=144&fit=crop&dpr=1 600w, https://images.theconversation.com/files/580527/original/file-20240307-28-o5dqjy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=144&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/580527/original/file-20240307-28-o5dqjy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=144&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/580527/original/file-20240307-28-o5dqjy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=181&fit=crop&dpr=1 754w, https://images.theconversation.com/files/580527/original/file-20240307-28-o5dqjy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=181&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/580527/original/file-20240307-28-o5dqjy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=181&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This excerpt from the July 3, 2021, state inspection report of Landmark of Louisville Rehabilitation and Nursing includes an interview with a nurse who found an injured resident.</span>
<span class="attribution"><a class="source" href="https://www.medicare.gov/care-compare/inspections/pdf/nursing-home/185122/health/standard?date=2021-07-03">New York State attorney general's office</a></span>
</figcaption>
</figure>
<h2>Persistent problems</h2>
<p>But problems persisted. Five months later, inspectors levied six additional deficiencies of immediate jeopardy − the highest level − including <a href="https://www.documentcloud.org/documents/24170103-landmark-nursing-120921#document/p1/a2407371">more sexual abuse</a> among residents and a certified nursing assistant pushing someone down, bruising the person’s back and hip.</p>
<p>Landmark is just one of the 58 facilities run by parent company Infinity Healthcare Management across five states. The government issued penalties to the company almost 4½ times the national average, according to bimonthly data that the Centers for Medicare & Medicaid Services first started to make available in late 2022. All told, Infinity paid <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">nearly $10 million in fines</a> since 2021, the highest among nursing home chains with fewer than 100 facilities.</p>
<p>Infinity Healthcare Management and its executives did not respond to multiple requests for comment.</p>
<p>Such <a href="https://violationtracker.goodjobsfirst.org/">sanctions are nothing new</a> for Infinity or other for-profit nursing home chains that have dominated an industry long known for cutting corners in pursuit of profits for private owners. But this race to the bottom to extract profits is accelerating despite demands by <a href="https://www.gao.gov/assets/gao-23-104813.pdf">government officials</a>, health care experts and advocacy groups to protect the nation’s most vulnerable citizens.</p>
<p>To uncover the reasons why, The Conversation’s investigative unit <em>Inquiry</em> delved into the nursing home industry, where for-profit facilities make up more than 72% of the nation’s nearly 14,900 facilities. The probe, which paired an academic expert with an investigative reporter, used the most recent government data on ownership, facility information and penalties, combined with CMS data on affiliated entities for nursing homes.</p>
<p>The investigation revealed an industry that places a premium on cost cutting and big profits, with low staffing and poor quality, often to the detriment of patient well-being. Operating under <a href="https://dx.doi.org/10.2139/ssrn.4541739">weak and poorly enforced regulations</a> with financially insignificant penalties, the for-profit sector fosters an environment where corners are frequently cut, compromising the quality of care and endangering patient health. Meanwhile, owners make the facilities look less profitable by siphoning money from the homes through byzantine networks of interconnected corporations. Federal regulators have neglected the problem as <a href="https://theconsumervoice.org/news/detail/latest/new-report-nursing-homes-funnel-dollars-through-related-party-companies">each year likely billions of dollars are funneled</a> out of nursing homes through related parties and into owners’ pockets.</p>
<h2>More trouble at midsize</h2>
<p>Analyzing newly released government data, our investigation found that these problems are most pronounced in nursing homes like Infinity − midsize chains that <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">operate between 11 and 100 facilities</a>. This subsection of the industry has higher average fines per home, lower overall quality ratings, and are more likely to be tagged with resident abuse compared with both the larger and smaller networks. Indeed, while such chains account for about 39% of all facilities, they operate 11 of the 15 most-fined facilities.</p>
<p><iframe id="zKmDk" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/zKmDk/5/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>With few impediments, private investors who own the midsize chains have quietly swooped in to purchase underperforming homes, expanding their holdings even further as larger chains divest and close facilities. As a result of the industry’s <a href="https://aspe.hhs.gov/sites/default/files/documents/dbab91af8491ce317a66471c361d3ec4/changes-ownership-snf.pdf">churn of facility ownership</a>, over one fifth of the country’s nursing facilities changed ownership between 2016 and 2021, four times more changes than hospitals.</p>
<p>A 2023 report by Good Jobs First, a nonprofit watchdog, noted that a dozen of these chains in the midsize range have <a href="https://goodjobsfirst.org/wp-content/uploads/2023/12/Upheaval-in-the-Nursing-Home-Industry.pdf">doubled or tripled in size</a> while racking up fines averaging over $100,000 per facility since 2018. But unlike the large, multistate chains with easily recognizable names, the midsize networks slip through without the same level of public scrutiny, The Conversation’s investigations unit found.</p>
<p>“They are really bad, but the names − we don’t know these names,” said Toby Edelman, senior policy attorney with the Center for Medicare Advocacy, a nonprofit law organization. </p>
<p>“When we used to have those multistate chains, the facilities all had the same name, so you know what the quality is you’re getting,” she said. “It’s not that good − but at least you know what you’re getting.”</p>
<p>In response to The Conversation’s findings on nursing homes and request for an interview, a CMS spokesperson emailed <a href="https://www.documentcloud.org/documents/24478510-nursing-home-information-request">a statement</a> that said the CMS is “unwavering in its commitment to improve safety and quality of care for the more than 1.2 million residents receiving care in Medicare- and Medicaid-certified nursing homes.”</p>
<p>The statement pointed to data released by the oversight body on <a href="https://www.hhs.gov/about/news/2022/04/20/hhs-releases-new-data-and-report-hospital-and-nursing-home-ownership.html">mergers, acquisitions, consolidations and changes of ownership</a> in April 2023 along with <a href="https://www.hhs.gov/about/news/2022/09/26/biden-harris-administration-makes-more-medicare-nursing-home-ownership-data-publicly-available-improving-identification-of-multiple-facilities-under-common-ownership.html">additional ownership data</a> released the following September. CMS also proposed a rule change that aims to increase transparency in nursing home ownership by <a href="https://www.federalregister.gov/documents/2024/02/16/2024-03294/agency-information-collection-activities-proposed-collection-comment-request">collecting more information on facility owners and their affiliations</a>.</p>
<p>“Our focus is on advancing implementable solutions that promote safe, high-quality care for residents and consider the challenging circumstances some long-term care facilities face,” the statement reads. “We believe the proposed requirements are achievable and necessary.”</p>
<p>CMS is slated to implement the disclosure rules in the fall and release the new data to the public later this year.</p>
<p>“We support transparency and accountability,” the American Health Care Association/National Center for Assisted Living, a trade organization representing the nursing home industry, <a href="https://www.documentcloud.org/documents/24475011-re-nursing-home-chains-and-cms-regulation-the-conversation-deadline-34-at-5pm-est">wrote in response</a> to The Conversation‘s request for comment. “But neither ownership nor line items on a budget sheet prove whether a nursing home is committed to its residents. Over the decades, we’ve found that strong organizations tend to have supportive and trusted leadership as well as a staff culture that empowers frontline caregivers to think critically and solve problems. These characteristics are not unique to a specific type or size of provider.”</p>
<p><iframe id="DRwGq" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/DRwGq/6/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>It often takes years to improve a poor nursing home − or <a href="https://www.newyorker.com/news/dispatch/when-private-equity-takes-over-a-nursing-home">run one into the ground</a>. The analysis of midsize chains shows that most owners have been associated with their current facilities for less than eight years, making it difficult to separate operators who have taken long-term investments in resident care from those who are looking to quickly extract money and resources <a href="https://www.wpr.org/st-louis-nursing-home-closes-suddenly-prompting-wider-concerns-over-care">before closing them down or moving on</a>. These chains control roughly 41% of nursing home beds in the U.S., according to CMS’s provider data, making the lack of transparency especially ripe for abuse.</p>
<p>A churn of nursing home purchases even during the COVID-19 pandemic shows that investors view the sector as <a href="https://doi.org/10.1111/jgs.17288">highly profitable</a>, especially when staffing costs are kept low and fines for poor care can easily be covered by the money extracted from residents, their families and taxpayers.</p>
<p>“This is the model of their care: They come in, they understaff and they make their money,” said Sam Brooks, director of public policy at the Consumer Voice, a national resident advocacy organization. “Then they multiply it over a series of different facilities.”</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/580534/original/file-20240307-30-57sogj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Side-by-side pictures of different nursing home residents asleep with their heads near dishes of food" src="https://images.theconversation.com/files/580534/original/file-20240307-30-57sogj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/580534/original/file-20240307-30-57sogj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=389&fit=crop&dpr=1 600w, https://images.theconversation.com/files/580534/original/file-20240307-30-57sogj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=389&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/580534/original/file-20240307-30-57sogj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=389&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/580534/original/file-20240307-30-57sogj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=488&fit=crop&dpr=1 754w, https://images.theconversation.com/files/580534/original/file-20240307-30-57sogj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=488&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/580534/original/file-20240307-30-57sogj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=488&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">These pictures showing residents asleep in their food appeared in the 2022 New York attorney general’s lawsuit against The Villages of Orleans Health and Rehabilitation Center in Albion, N.Y.</span>
<span class="attribution"><a class="source" href="https://ag.ny.gov/sites/default/files/orleans_nh_petition.pdf">New York State attorney general's office</a></span>
</figcaption>
</figure>
<h2>Investor race</h2>
<p>The explosion of a billion-dollar private marketplace found its beginnings in government spending.</p>
<p>The adoption of Medicare and Medicaid in 1965 set loose a race among investors to load up on nursing homes, with a surge in for-profit homes gaining momentum because of a reliable stream of government payouts. By 1972, a mere seven years after the inception of the programs, a whopping <a href="https://babel.hathitrust.org/cgi/pt?id=umn.31951d00930792n&view=1up&seq=20">106 companies </a>had rushed to Wall Street to sell shares in nursing home companies. And little wonder: They pulled in profits through their ownership of 18% of the industry’s beds, securing about a third of the hefty $3.2 billion of government cash.</p>
<p>The 1990s saw substantial expansion in for-profit nursing home chains, marked by a wave of <a href="https://aspe.hhs.gov/reports/nursing-home-divestiture-corporate-restructuring-final-report-0">acquisitions and mergers</a>. At the same time, increasing difficulties emerged in the model for publicly traded chains. <a href="https://www.jstor.org/stable/45140855">Shareholders increasingly demanded</a> rapid growth, and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442234/">researchers have found</a> that the publicly traded chains tried to appease that hunger by reducing nursing staff and cutting corners on other measures meant to improve quality and safety.</p>
<p>“I began to suspect a possibly inherent contradiction between publicly traded and other large investor-operated nursing home companies and the prerequisites for quality care,” Paul R. Willging, former chief lobbyist for the industry, wrote in a 2007 letter to the editor of The New York Times. “For many investors … earnings growth, quarter after quarter, is often paramount. Long-term investments in quality can work at cross purposes with a mandate for an unending progression of favorable earnings reports.”</p>
<p>One example of that clash can be found at the Ensign Group, <a href="https://www.sec.gov/Archives/edgar/data/1125376/000112537613000022/ensg12311210k.htm">founded in 1999 as a private chain of five facilities</a>. Using a strategy of acquiring struggling nursing homes, the company <a href="https://www.sec.gov/Archives/edgar/data/1125376/000112537613000022/ensg12311210k.htm">went public in 2007 with more than 60 facilities</a>. What followed was a year-after-year acquisition binge and a track record of growing <a href="https://journals.sagepub.com/doi/full/10.1177/00207314221077649">profits almost every year</a>. Yet the company <a href="https://journals.sagepub.com/doi/full/10.1177/00207314221077649">kept staffing levels below</a> the national average and <a href="https://www.justice.gov/sites/default/files/elderjustice/legacy/2015/07/12/Appropriateness_of_Minimum_Nurse_Staffing_Ratios_in_Nursing_Homes.pdf">levels recommended by experts</a>. <a href="https://journals.sagepub.com/doi/full/10.1177/00207314221077649">Its facilities had</a> higher than average inspection deficiencies and higher COVID infection rates. Since 2021, it has racked up more than <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">$6.5 million in penalties</a>.</p>
<p>Ensign did not respond to requests for comment. </p>
<p>Even with that kind of expense cutting, not all publicly traded nursing homes survived as the costs of providing poor care added up. Residents sued over mistreatment. Legal fees and settlements ate into profits, shareholders grumbled, and executives searched for a way out of this Catch-22.</p>
<p>Recognizing the long-term potential for profit growth, private investors snapped up publicly traded for-profit chains, reducing the previous levels of public transparency and oversight. Between 2000 and 2017, 1,674 nursing homes were <a href="https://doi.org/10.1093/rfs/hhad082">acquired by private-equity firms</a> in 128 unique deals out of 18,485 facilities. But the same poor-quality problems persisted. Research shows that after snagging a big chain, private investors tended to follow the same playbook: They <a href="https://doi.org/10.1093/ppar/prad001">rebrand the company, increase corporate control and dump</a> unprofitable homes to other investment groups willing to take shortcuts for profit.</p>
<p><a href="https://doi.org/10.1093/ppar/prad001">Multiple</a> <a href="http://dx.doi.org/10.2139/ssrn.3860353">academic</a> <a href="https://doi.org/10.1093/rfs/hhad082">studies</a> show the results, highlighting the lower staffing and quality in for-profit homes compared with nonprofits and government-run facilities. Elderly residents staying long term in nursing homes owned by private investment groups experienced <a href="https://doi.org/10.1093/ppar/prad001">a significant uptick</a> in trips to the emergency department and hospitalizations between 2013 and 2017, translating into higher costs for Medicare. </p>
<p>Overall, private-equity investors <a href="https://aspe.hhs.gov/sites/default/files/documents/29b280bc8ec7632e5742ab466f5429d2/ownership-structures-nh-facility-traits.pdf">wreak havoc</a> on nursing homes, slashing registered nurse hours per resident day by 12%, outpacing other for-profit facilities. The aftermath is grim, with a daunting 14% surge in the deficiency score index, a standardized metric for determining issues with facilities, according to a U.S. Department of Health and Human Services report.</p>
<p><iframe id="vmclY" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/vmclY/9/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>The human toll comes in death and suffering. A study updated in 2023 by the National Bureau of Economic Research <a href="https://doi.org/10.1093/rfs/hhad082">calculated that 22,500 additional deaths</a> over a 12-year span were attributable to private-equity ownership, equating to about 172,400 lost life years. The calculations also showed that private-equity ownership was responsible for a 6.2% reduction in mobility, an 8.5% increase in ulcer development and a 10.5% uptick in pain intensity.</p>
<h2>Hiding in complexity</h2>
<p>Exposing the identities of who should be held responsible for such anguish poses a formidable task. Private investors in nursing home chains often employ a <a href="https://doi.org/10.1080/08959420.2012.705702">convoluted system</a> of limited liability corporations, related companies and family relationships <a href="https://theconsumervoice.org/news/detail/latest/new-report-nursing-homes-funnel-dollars-through-related-party-companies">to obscure who controls</a> the nursing homes. </p>
<p>These adjustments are crafted to minimize liability, capitalize on favorable tax policies, diminish regulatory scrutiny and disguise nursing home profitability. In this investigation, entities at every level of involvement with a nursing home denied ownership, even though the same people controlled each organization.</p>
<p>A <a href="https://www.federalregister.gov/documents/2023/11/17/2023-25408/medicare-and-medicaid-programs-disclosures-of-ownership-and-additional-disclosable-parties">rule put in place in 2023</a> by the Centers for Medicare & Medicaid Services requires the identification of all private-equity and real estate investment trust investors in a facility and the release of all related party names. But this hasn’t been enough to surface the players and relationships. More than half of ownership data provided to CMS is incomplete across all facilities, according to a <a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2023.01110">March 2024 analysis</a> of the newly released data.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/579969/original/file-20240305-20-bjd535.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Complicated graphic with 21 intertwined items" src="https://images.theconversation.com/files/579969/original/file-20240305-20-bjd535.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/579969/original/file-20240305-20-bjd535.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=423&fit=crop&dpr=1 600w, https://images.theconversation.com/files/579969/original/file-20240305-20-bjd535.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=423&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/579969/original/file-20240305-20-bjd535.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=423&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/579969/original/file-20240305-20-bjd535.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=531&fit=crop&dpr=1 754w, https://images.theconversation.com/files/579969/original/file-20240305-20-bjd535.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=531&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/579969/original/file-20240305-20-bjd535.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=531&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Nursing home investors drained more than $18 million out of a single facility through a complex web of related party transactions.</span>
<span class="attribution"><a class="source" href="https://ag.ny.gov/sites/default/files/villages_memorandum_of_law.pdf">New York State attorney general's office</a></span>
</figcaption>
</figure>
<p>Even the land under the nursing home is often owned by someone else. In 2021, publicly traded or private real estate investment trusts <a href="https://doi.org/10.1377/hlthaff.2022.00278">held a sizable chunk</a> of the approximately $120 billion of nursing home real estate. As with homes owned by private-equity investors, <a href="https://aspe.hhs.gov/sites/default/files/documents/29b280bc8ec7632e5742ab466f5429d2/ownership-structures-nh-facility-traits.pdf">quality measures collapse</a> after REITs get involved, with facilities witnessing a 7% decline in registered nurses’ hours per resident day and an alarming 14% ascent in the deficiency score index. It’s a blatant pattern of disruption, leaving facilities and care standards in a dire state.</p>
<p>Part of that quality collapse comes from the way these investment entities make their money. REITs and their owners <a href="https://doi.org/10.1377/hlthaff.2022.00278">can drain cash out</a> of the nursing homes in a number of different ways. The standard tactic for grabbing the money is known as a triple-net lease, where the REIT buys the property then leases it back to the nursing home, often <a href="https://ssrn.com/abstract=4209720">at exorbitant rates</a>. Although the nursing home then lacks possession of the property, it still gets slammed with costs typically shouldered by an owner − real estate taxes, insurance, maintenance and more. Topping it off, the facilities then must typically pay annual rent hikes.</p>
<p>A second tactic that REITs use involves a contracting façade that serves no purpose other than enriching the owners of the trusts. Since triple-net lease agreements prohibit REITs from taking profits from operating the facilities, the investors create a subsidiary to get past that hurdle. The subsidiary then contracts with a nursing home operator − often owned or controlled by another related party − and then demands a fee for providing operational guidance. The use of REITs for near-risk-free profits from nursing homes has proven to be an ever-growing technique, and <a href="https://aspe.hhs.gov/sites/default/files/documents/29b280bc8ec7632e5742ab466f5429d2/ownership-structures-nh-facility-traits.pdf">the midsize chains</a>, which our investigation found generally provided the worst care, grew in their reliance on REITs during the pandemic.</p>
<p>“When these REITs start coming in … nursing homes are saddled with these enormous rents, and then they wind up going out of business,” said Richard Mollot, executive director of the <a href="https://nursinghome411.org/">Long-Term Care Community Coalition</a>, a nonprofit organization that advocates for better care at nursing homes. “It’s no longer a viable facility.”</p>
<p>The churn of nursing home purchases by midsize chains underscores investors’ perception of the sector’s profitability, particularly when staffing expenses are minimized and penalties for subpar care can be offset by money extracted through related transactions and payments from residents, their families and taxpayers. Lawsuits can drag out over years, and in the worst case, if a facility is forced to close, its land and other assets can be sold to minimize the financial loss.</p>
<p>Take Brius Healthcare, a name that resonates with a disturbing cadence in the world of nursing home ownership. A search of the federal database for nursing home ownership and penalties shows that Brius was <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">responsible for 32 facilities</a> as of the start of 2024, but the true number is <a href="http://briuswatch.org/brius-facilities/">closer to 80</a>, according to BriusWatch.org, which tracks violations. At the helm of this still midsize network stands Shlomo Rechnitz, who became a billionaire in part <a href="https://www.documentcloud.org/documents/24225027-us-v-brius">by siphoning from government payments</a> to his facilities scattered across California, according to a federal and state lawsuit.</p>
<p><a href="https://s3.documentcloud.org/documents/21069802/complaint-2.pdf">In lawsuits</a> and regulators’ criticisms, Rechnitz’s homes <a href="http://briuswatch.org/wp-content/uploads/2018/08/2018-06-12-Campbell-v-RechnitzAlamedaHWCet.al_..pdf">have been associated</a> with tales of abuse, as well as several lawsuits alleging terrible care. The track record was so bad that, in the summer of 2014, then-California Attorney General Kamala Harris filed an <a href="https://www.scribd.com/doc/268424325/Emergency-Motion-Calif-AG-8-28-14?secret_password=GhxgjwaQFhWc8aNGjmWj">emergency motion</a> to block Rechnitz from acquiring 19 facilities, writing that he was “a serial violator of rules within the skilled nursing industry” and was “not qualified to assume such an important role.”</p>
<p>Yet, Rechnitz’s empire in California surged forward, scooping up more facilities that drained hundreds of millions of federal and state funds as they <a href="https://www.washingtonpost.com/business/2020/12/31/brius-nursing-home/">racked up pain and profit</a>. The narrative played out at Windsor Redding Care Center in Redding, California. Rechnitz bought it from a competing nursing home chain and attempted to obtain a license to operate the facility. But in 2016, the California Department of Public Health <a href="https://canhr.org/wp-content/uploads/2022/10/River-Valley-Healthcare-and-Wellness-Centre-CHOW-Denial-1.pdf">refused the application</a>, citing a staggering 265 federal regulatory violations across his other nursing homes over just three years.</p>
<p>According to court filings, Rechnitz formed <a href="https://www.documentcloud.org/documents/24460115-brius-redding_042722#document/p7/a2433390">a joint venture with other investors</a> who in turn held the license. Rechnitz, through the Brius joint venture, became the unlicensed owner and operator of Windsor Redding.</p>
<p>Brius carved away at expenses, <a href="https://www.documentcloud.org/documents/24223812-windsor-nursing">slashing staff and other care necessities</a>, according to a 2022 California lawsuit. One resident was left to sit in her urine and feces for hours at a time. Overwhelmed staff often did not respond to her call light, so once she instead climbed out of bed unassisted, fell and fractured her hip. Other negligence led to pressure ulcers, and when she was finally transferred to a hospital, she was suffering from sepsis. She was not alone in her suffering. <a href="https://www.documentcloud.org/documents/24224925-windsor">Numerous other residents</a> experienced an unrelenting litany of injuries and illnesses, including pressure ulcers, urinary tract infections from poor hygiene, falls, and skin damage from excess moisture, according to the lawsuit.</p>
<p>In 2023, California moved forward with <a href="https://calmatters.org/wp-content/uploads/2023/06/CHOW-Settlement-Agreement-MAJ-SR-KRS-CD-signed-FINAL.pdf">licensing two dozen</a> of Rechnitz’s facilities with an agreement that included a two-year monitoring period, <a href="https://calmatters.org/health/2023/06/nursing-homes-california/">right before statewide reforms</a> were set to take effect. The reforms don’t prevent existing owners like Rechnitz from continuing to run a nursing home without a license, but they do prevent new operators from doing so.</p>
<p>“We’re seeing more of that, I think, where you have a proliferation of really bad operators that keep being provided homes,” said Brooks, the director of public policy at the Consumer Voice. “There’s just so much money to be made here for unscrupulous people, and it just happens all the time.”</p>
<p>Rechnitz did not respond to multiple requests for comment. Bruis also did not respond.</p>
<p>Perhaps no other chain showcases the havoc that can be caused by one individual’s acquisition of multiple nursing homes than <a href="https://skillednursingnews.com/2019/04/nursing-homes-held-by-skyline-owner-face-crisis-bouncing-paychecks-in-mass/">Skyline Health Care</a>. The company’s owner, Joseph Schwartz, parlayed the sale of his insurance business into ownership of 90 facilities between mid-2016 and December 2017, according to a <a href="https://www.documentcloud.org/documents/24170670-skylineindictment">federal indictment</a>. He ran the company out of an office <a href="https://www.govinfo.gov/content/pkg/USCOURTS-mdd-1_20-cv-01353/pdf/USCOURTS-mdd-1_20-cv-01353-0.pdf">above a New Jersey pizzeria</a> and at its peak managed facilities in 11 states.</p>
<p>Schwartz went all-in on cost cutting, and by early 2018, residents were suffering from the shortage of staff. The company <a href="https://www.medicareadvocacy.org/wp-content/uploads/2018/09/Centers-Statement-on-Nursing-Home-Hearing.pdf">wasn’t paying its bills</a> or its <a href="https://www.mass.gov/news/skyline-healthcare-owner-five-massachusetts-nursing-homes-cited-for-wage-theft">workers</a>. More than a dozen lawsuits piled up. Last year, Schwartz was arrested and faced charges in federal district court in New Jersey for his role in a <a href="https://www.justice.gov/opa/pr/owner-health-care-and-rehabilitation-facilities-indicted-38-million-payroll-tax-scheme">$38 million payroll tax scheme</a>. In 2024, Schwartz <a href="https://www.justice.gov/usao-nj/pr/insurance-producer-admits-tax-fraud-scheme">pleaded guilty</a> to his role in the fraud scheme. He is awaiting sentencing, where he <a href="https://www.documentcloud.org/documents/24443941-schwartz_plea_20240117">faces a year in prison</a> along with paying at least $5 million in restitution.</p>
<p>Skyline collapsed and <a href="https://www.nbcnews.com/health/aging/nursing-home-chain-grows-too-fast-collapses-elderly-disabled-residents-n1025381">disrupted thousands of lives</a>. Some states took over facilities; others closed, forcing residents to relocate and throwing families into chaos. The case also highlights the ease with which some bad operators can snap up nursing homes with little difficulty, with federal and state governments allowing ownership changes with little or no review.</p>
<p>Schwartz’s lawyer did not respond to requests for comment.</p>
<p>Not that nursing homes have much to fear in the public perception of their reputation for quality. CMS uses what is known as the <a href="https://www.cms.gov/medicare/health-safety-standards/certification-compliance/five-star-quality-rating-system">Five-Star Quality Rating System</a>, designed to help consumers compare nursing homes to find one that provides good care. Theoretically, nursing homes with five-star ratings are supposed to be exceptional, while those with one-star ratings are deemed the worst. But research shows that nursing homes <a href="https://doi.org/10.1177/1077558717739214">can game the system</a>, with the result that a top star rating might reflect little more than a facility’s willingness to cheat.</p>
<p>A star rating is composed of three parts: The score from a government inspection and the facility’s self-reports of staffing and quality. This means that what the nursing homes say about themselves can boost the star rating of facilities even if they have poor inspection results.</p>
<p><a href="https://nihcm.org/publications/do-nursing-homes-inflate-their-medicare-star-ratings-by-self-reporting-overly-positive-assessments">Multiple studies</a> have highlighted a concerning trend: Some nursing homes, especially for-profit ones, <a href="https://doi.org/10.1002/smj.3063">inflate their self-reported measures</a>, resulting in a disconnect from actual inspection findings. Notably, research suggests that for-profit nursing homes, driven by significant financial motives, are more likely to engage in this practice of inflating their self-reported assessments.</p>
<p>At bottom, the elderly and their families seeking quality care unknowingly find themselves in an impossible situation with for-profit nursing homes: Those facilities tend to provide the worst quality, and the only measure available for consumers to determine where they will be treated well can be rigged. The result is the transformation of an industry meant to care for the most vulnerable into a profit-driven circus.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/579741/original/file-20240305-20-b5d09r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Close-up of an elderly woman's head leaning on her hand" src="https://images.theconversation.com/files/579741/original/file-20240305-20-b5d09r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/579741/original/file-20240305-20-b5d09r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/579741/original/file-20240305-20-b5d09r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/579741/original/file-20240305-20-b5d09r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/579741/original/file-20240305-20-b5d09r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/579741/original/file-20240305-20-b5d09r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/579741/original/file-20240305-20-b5d09r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The for-profit nursing home sector is growing, and it places a premium on cost cutting and big profits, which has led to low staffing and patient neglect and mistreatment.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/february-2024-baden-württemberg-na-a-resident-of-a-nursing-news-photo/1985540302">picture alliance via Getty Images</a></span>
</figcaption>
</figure>
<h2>The pandemic</h2>
<p>Nothing more clearly exposed the problems rampant in nursing homes than the pandemic. Throughout that time, <a href="https://data.cms.gov/covid-19/covid-19-nursing-home-data">nursing homes reported</a> that almost 2 million residents had infections and 170,000 died.</p>
<p>No one should have been surprised by the mass death in nursing homes − the warning signs of what was to come had been visible for years. Between 2013 and 2017, infection control was the <a href="https://www.gao.gov/assets/gao-20-576r.pdf">most frequently cited deficiency</a> in nursing homes, with 40% of facilities cited each year and 82% cited at least once in the five-year period. Almost half were cited over multiple consecutive years for these deficiencies − if fixed, one of the big causes of the widespread transmission of COVID in these facilities would have been eliminated.</p>
<p>But shortly after coming into office in 2017, the Trump administration weakened what was already a deteriorating system to regulate nursing homes. The administration <a href="https://www.nytimes.com/2017/12/24/business/trump-administration-nursing-home-penalties.html">directed regulators to issue one-time fines</a> against nursing homes for violations of federal rules rather than for the full time they were out of compliance. This shift meant that even nursing homes with severe infractions lasting weeks were exempted from fines surpassing the maximum per-instance penalty of $20,965.</p>
<p>Even that near-worthless level of regulation was not feeble enough for the industry, so lobbyists pressed for less. In response, just a few months before COVID emerged in China, the Trump administration <a href="https://www.federalregister.gov/documents/2019/07/18/2019-14946/medicare-and-medicaid-programs-requirements-for-long-term-care-facilities-regulatory-provisions-to">implemented new regulations</a> that effectively abolished a mandate for each to hire a full-time infection control expert, instead <a href="https://www.americanprogress.org/article/trump-administrations-deregulation-nursing-homes-leaves-seniors-disabled-higher-risk-covid-19/">recommending outside consultants</a> for the job.</p>
<p>The perfect storm had been reached, with no experts required to be on site, prepared to combat any infection outbreaks. On Jan. 20, 2020 − just 186 days after the change in rules on infection control − the CDC <a href="https://www.cdc.gov/museum/timeline/covid19.html#:%7E:text=January%2020%2C%202020,respond%20to%20the%20emerging%20outbreak.">reported that the first</a> laboratory-confirmed case of COVID had been found at a nursing home in Washington state.</p>
<p>The least prepared in this explosion of disease were the for-profit nursing homes, compared with nonprofit and government facilities. Research from the University of California at San Francisco found those facilities were <a href="https://doi.org/10.1177/1527154420938707">linked to higher numbers</a> of COVID cases. For-profits not only had fewer nurses on staff but also high numbers of infection-control deficiencies and lower compliance with health regulations.</p>
<p>Even as the United States went through the crisis, some owners of midsize chains continued snapping up nursing homes. For example, two Brooklyn businessmen named Simcha Hyman and Naftali Zanziper were going on a nursing home <a href="https://pe-insights.com/news/2020/08/07/as-the-pandemic-struck-a-private-equity-firm-went-on-a-nursing-home-buying-spree/">buying spree</a> through their private-equity company, the Portopiccolo Group. <a href="https://www.washingtonpost.com/local/portopiccolo-nursing-homes-maryland/2020/12/21/a1ffb2a6-292b-11eb-9b14-ad872157ebc9_story.html">Despite poor ratings</a> in their previously owned facilities, nothing blocked the acquisitions.</p>
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<p>One such facility was a struggling nursing home in North Carolina now known as The Citadel Salisbury. Following the traditional pattern forged by private investors in the industry, the new owners set up a <a href="https://www.documentcloud.org/documents/24174455-citadellawsuit_051721#document/p18/a2409687">convoluted network of business</a> entities and then used them to charge the nursing home for services and property. A 2021 federal lawsuit of many plaintiffs claimed that they deliberately <a href="https://www.classaction.org/media/hooker-et-al-v-the-citadel-salisbury-llc-et-al.pdf">kept the facility understaffed</a> and undersupplied to maximize profit.</p>
<p>Within months of the first case of COVID reported in America, The Citadel Salisbury experienced the largest nursing home outbreak in the state. The situation was so dire that on April 20, 2020, the local medical director of the emergency room <a href="https://www.salisburypost.com/2020/04/20/john-bream-outbreak-at-citadel-nursing-home-especially-concerning/">took to the local newspaper</a> to express his distress, revealing that he had pressed the facility’s leadership and the local health department to address the known shortcomings.</p>
<p>The situation was “a blueprint for exactly what not to do in a crisis,” medical director John Bream wrote. “Patients died at the Citadel without family members being notified. Families were denied the ability to have one last meaningful interaction with their family. Employees were wrongly denied personal protective equipment. There has been no transparency.”</p>
<p>After a <a href="https://www.documentcloud.org/documents/24174486-citadelinspection_090221">series of scathing inspection reports</a>, the <a href="https://www.cms.gov/files/document/north-carolina-citadel-salisbury-05-04-2022.pdf">facility finally closed</a> in the spring of 2022. As for the federal lawsuit, court documents show that a tentative agreement was reached in 2023. But the case dragged out for nearly three years, and one of the plaintiffs, Sybil Rummage, <a href="https://www.documentcloud.org/documents/24174489-deathrecord_102423">died while seeking accountability</a> through the court.</p>
<p>Still, the pandemic had been a time of great success for Hyman and Zanziper. At the end of 2020, they owned more than 70 facilities. By 2021, their portfolio had exploded to more than 120. Now, according to data from the Centers for Medicare & Medicaid Services, Hyman and Zanziper are associated with at least 131 facilities and have the highest amount of total fines recorded by the agency for affiliated entities, totaling nearly $12 million since 2021. And their average fine per facility, as calculated by CMS, is <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">more than twice the national average</a> at almost $90,000.</p>
<p>In a <a href="https://www.documentcloud.org/documents/24459663-media-request-the-conversation-nursing-home-regulations-and-portopiccolo-deadline-124-12pm">written statement</a>, Portopiccolo Group spokesperson John Collins disputed that the facilities had skimped on care and argued that they were not managed by the firm. “We hire experienced, local health care teams who are in charge of making all on-the-ground decisions and are committed to putting residents first.” He added that the number of facilities given by CMS was inaccurate but declined to say how many are connected to its network of affiliates or owned by Hyman and Zanziper.</p>
<p>With the nearly 170,000 resident deaths from COVID and many related fatalities from isolation and neglect in nursing homes, in February 2022 President Biden <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/">announced an initiative</a> aimed at improving the industry. In addition to promising to set a minimum staffing standard, the initiative is focused on improving ownership and financial transparency.</p>
<p>“As Wall Street firms take over more nursing homes, quality in those homes has gone down and costs have gone up. That ends on my watch,” Biden said during his 2022 State of the Union address. “Medicare is going to set higher standards for nursing homes and make sure your loved ones get the care they deserve and expect.”</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/579699/original/file-20240304-189996-65mwly.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="President Biden sitting at a desk signing with a crowd gathered around him" src="https://images.theconversation.com/files/579699/original/file-20240304-189996-65mwly.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/579699/original/file-20240304-189996-65mwly.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/579699/original/file-20240304-189996-65mwly.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/579699/original/file-20240304-189996-65mwly.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/579699/original/file-20240304-189996-65mwly.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/579699/original/file-20240304-189996-65mwly.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/579699/original/file-20240304-189996-65mwly.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">President Joe Biden signed an executive order on April 18, 2023, that directed the secretary of health and human services to consider actions that would build on nursing home minimum staffing standards and improve staff retention.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/president-joe-biden-signs-an-executive-order-in-the-rose-news-photo/1251960535">Nathan Posner/Anadolu Agency via Getty Images</a></span>
</figcaption>
</figure>
<p>Still, the <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2023/09/01/fact-sheet-biden-harris-administration-takes-steps-to-crack-down-on-nursing-homes-that-endanger-resident-safety/">current trajectory of actions</a> appears to fall short of what’s needed. While penalties against facilities have sharply increased under Biden, some of the Trump administration’s weak regulations have not been replaced. </p>
<p>A <a href="https://www.reginfo.gov/public/do/eAgendaViewRule?pubId=202310&RIN=0938-AV25">rule</a> proposed by CMS in September 2023 and <a href="https://www.reginfo.gov/public/do/eoDetails?rrid=431762">released for review</a> in March 2024 would require states to report what percentage of Medicaid funding is used to pay direct care workers and support staff and would <a href="https://www.cms.gov/newsroom/fact-sheets/medicare-and-medicaid-programs-minimum-staffing-standards-long-term-care-facilities-and-medicaid">require an RN on duty 24/7. It would also require a minimum of three hours</a> of skilled staffing care per patient per day. But the three-hour minimum is substantially lower than the 4.1 hours of skilled staffing for nursing home residents <a href="https://www.justice.gov/sites/default/files/elderjustice/legacy/2015/07/12/Appropriateness_of_Minimum_Nurse_Staffing_Ratios_in_Nursing_Homes.pdf">suggested by CMS over two decades ago</a>.</p>
<p>The requirements are also lower than the <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">3.8 average nursing staff hours</a> already employed by U.S. facilities.</p>
<p>The current administration has also let stand the <a href="https://www.cms.gov/newsroom/press-releases/cms-rules-put-patients-first-updating-requirements-arbitration-agreements-and-new-regulations-put#:%7E:text=CMS%20is%20allowing%20binding%20arbitration,to%20sign%20a%20binding%20arbitration">Trump administration reversal</a> of an Obama rule that banned binding arbitration agreements in nursing homes.</p>
<h2>It breaks a village</h2>
<p>The Villages of Orleans Health and Rehabilitation Center in Albion, New York, was, by any reasonable measure, broken. Court records show that <a href="https://www.documentcloud.org/documents/24438756-e22_00582_people_of_the_state_of_v_people_of_the_state_of_exhibit_s__16">on some days there was no nurse and no medication</a> for the more than 100 elderly residents. Underpaid staff <a href="https://www.documentcloud.org/documents/24444996-orleans_nh_petition#document/p112/a2431650">spent their own cash for soap</a> to keep residents clean. At times, the home <a href="https://www.documentcloud.org/documents/24444996-orleans_nh_petition#document/p40/a2431651">didn’t feed</a> its frail occupants.</p>
<p>Meanwhile, according to a 2022 lawsuit filed by the New York attorney general, <a href="https://www.documentcloud.org/documents/24444996-orleans_nh_petition#document/p8/a2431653">riches were siphoned out of the nursing home</a> and into the pockets of the official owner, Bernard Fuchs, as well as assorted friends, business associates and family. The lawsuit says $18.7 million flowed from the facility to entities owned by a group of men who controlled the Village’s operations.</p>
<p>Although these men own various nursing homes, Medicare records show few connections between them, despite them all being investors in Comprehensive Healthcare Management, which provided administrative services to the Villages. Either they or their families were also owners of Telegraph Realty, which <a href="https://www.documentcloud.org/documents/24444996-orleans_nh_petition#document/p11/a2431654">leased what was once the Villages’ own property back</a> to the facility at rates the New York attorney general deemed exorbitant, predatory and a sham.</p>
<p>So it goes in the world of nursing home ownership, where overlapping entities and investors obscure the interrelationships between them to such a degree that Medicare itself is never quite sure who owns what.</p>
<p>Glenn Jones, a lawyer representing Comprehensive Healthcare Management, declined to comment on the pending litigation, but he forwarded a <a href="https://www.documentcloud.org/documents/24444995-2023-04-17-296-mol-in-support-of-nom-to-dismiss-4881-0186-0702-1">court document his law firm filed</a> that labels the allegations brought by the New York attorney general “unfounded” and reliant on “a mere fraction” of its residents.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/580541/original/file-20240307-16-qd3106.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Side-by-side pictures of a man in a wheelchair with glasses in November, 2019 and the same man looking less alert, unshaven and with an eye wound in December, 2019" src="https://images.theconversation.com/files/580541/original/file-20240307-16-qd3106.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/580541/original/file-20240307-16-qd3106.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=334&fit=crop&dpr=1 600w, https://images.theconversation.com/files/580541/original/file-20240307-16-qd3106.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=334&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/580541/original/file-20240307-16-qd3106.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=334&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/580541/original/file-20240307-16-qd3106.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=420&fit=crop&dpr=1 754w, https://images.theconversation.com/files/580541/original/file-20240307-16-qd3106.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=420&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/580541/original/file-20240307-16-qd3106.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=420&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">These pictures of the same resident one month apart at the Holliswood Center for Rehabilitation and Healthcare in Queens appeared in a 2023 New York attorney general lawsuit against 13 LLCs and 14 individuals. The group owns multiple nursing homes and allegedly neglected residents, while owners siphoned Medicare and Medicaid money into their own pockets.</span>
<span class="attribution"><a class="source" href="https://ag.ny.gov/sites/default/files/court-filings/centers-filed-petition.pdf">New York attorney general's office</a></span>
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</figure>
<p>The shadowy structure of ownership and related party transactions plays an enormous role in how investors enrich themselves, even as the nursing homes they control struggle financially. Compounding the issue, the figures reported by nursing homes regarding payments to related parties <a href="https://theconsumervoice.org/news/detail/latest/new-report-nursing-homes-funnel-dollars-through-related-party-companies">frequently diverge</a> from the disclosures made by the related parties themselves.</p>
<p>As an illustration of the problems, consider <a href="https://pruitthealth.com/">Pruitt Health</a>, a midsize chain with <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">87 nursing homes</a> spread across Georgia, South Carolina, North Carolina and Florida that had low overall federal quality ratings and about $2 million in penalties. A report by The National Consumer Voice For Quality Long-Term Care, a consumer advocacy group, <a href="https://theconsumervoice.org/news/detail/latest/new-report-nursing-homes-funnel-dollars-through-related-party-companies">shows that Pruitt disclosed</a> general related party costs nearing $482 million from 2018 to 2020. Yet in that same time frame, Pruitt reported payments to specific related parties amounting to about $570 million, indicating a $90 million excess. Its federal disclosures offer no explanation for the discrepancy. Meanwhile, the company reported $77 million in overall losses on its homes.</p>
<p>The same pattern holds in the major chains such as the Cleveland, Tennessee-based Life Care Centers of America, which operates roughly 200 nursing homes across 27 states, according to the report. Life Care’s financial disbursements are fed into a diverse spectrum of related entities, including management, staffing, insurance and therapy companies, all firmly under the umbrella of the organization’s ownership. In fiscal year 2018, the financial commitment to these affiliated entities reached $386,449,502; over the three-year period from 2018 to 2020, Life Care’s documented payments to such parties hit an eye-popping $1.25 billion.</p>
<p>Pruitt Health and Life Care Centers did not respond to requests for comment.</p>
<p>Overall, <a href="https://journals.sagepub.com/doi/10.1177/27551938231221509">77% of US nursing homes reported $11 billion</a> in related-party transactions in 2019 − nearly 10% of total net revenues − but the data is unaudited and unverified. The facilities <a href="https://theconsumervoice.org/news/detail/latest/new-report-nursing-homes-funnel-dollars-through-related-party-companies">are not required to provide any details</a> of what specific services were provided by the related parties, or what were the specific profits and administrative costs, creating a lack of transparency regarding expenses that are ambiguously categorized under generic labels such as “maintenance.” Significantly, there is no mandate to disclose whether any of these costs exceed fair market value.</p>
<p>What that means is that nursing home owners can profit handsomely through related parties even if their facilities are being hit with repeated fines for providing substandard care.</p>
<p>“What we would consider to be a big penalty really doesn’t matter because there’s so much money coming in,” said Mollot of the Long-Term Care Community Coalition. “If the facility fails, so what? It doesn’t matter. They pulled out the resources.’’</p>
<p><iframe id="DGcNl" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/DGcNl/6/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Hiding profit</h2>
<p>Ultimately, experts say, this ability to drain cash out of nursing homes makes it almost impossible for anyone to assess the profitability of these facilities based on their public financial filings, known as cost reports.</p>
<p>"The profit margins (for nursing homes) also should be taken with a grain of salt in the cost reports,” said Dr. R. Tamara Konetzka, a University of Chicago professor of public health sciences, at a <a href="https://nursinghome411.org/policybriefing-dec28/">recent meeting</a> of the <a href="https://www.medpac.gov/">Medicare Payment Advisory Commission</a>. “If you sell the real estate to a REIT or to some other entity, and you pay sort of inflated rent back to make your profit margins look lower, and then you recoup that profit because it’s a related party, we’re not going to find that in the cost reports.”</p>
<p>That ability to hide profits is key to nursing homes’ ability to block regulations to improve quality of care and to demand greater government payments. For decades, the <a href="https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/Long-Term-Care-Closures-Mount-As-COVID-19-Exacerbates-Financial-Shortfalls.aspx">industry’s refrain</a> has been that cuts in reimbursements or requirements to increase staffing will drive facilities into bankruptcy; already, they claim, half of all nursing homes are teetering on the edge of collapse, <a href="https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/Long-Term-Care-Closures-Mount-As-COVID-19-Exacerbates-Financial-Shortfalls.aspx">the result, they say, of inadequate Medicaid rates</a>. All in all, the industry reports that <a href="https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/Long-Term-Care-Closures-Mount-As-COVID-19-Exacerbates-Financial-Shortfalls.aspx">less than 3%</a> of their revenue goes to earnings.</p>
<p>But that does not include any of the revenue pulled out of the homes to boost profits of related parties controlled by the same owners pleading poverty. And this tactic is only one of several ways that the nursing home industry disguises its true profits, giving it the power to plead poverty to an unknowing government.</p>
<p>Under the regulations, <a href="https://journals.sagepub.com/doi/10.1177/27551938231221509">only certain nursing home expenses are reimbursable</a>, such as money spent for care. Many others − unreasonable payments to the headquarters of chains, luxury items, and fees for lobbyists and lawyers − are disallowed after Medicare reviews the cost reports. But by that time, the government has already reimbursed the nursing homes for those expenses − and <a href="https://doi.org/10.1177/27551938231221509">none of those revenues have to be returned</a>.</p>
<p>Data indicates that owners also profit by overcharging nursing homes for services and leases provided by related entities. A March 2024 study from Lehigh University and the University of California, Los Angeles <a href="https://ucla.app.box.com/v/RelatedParties">shows that costs were inflated</a> when nursing home owners changed from independent contractors to businesses owned or controlled directly or indirectly by the same people. Overall, spending on real estate increased 20.4%, and spending on management increased 24.6% when the businesses were affiliated, the research showed.</p>
<p>Nursing homes also claim that <a href="https://journals.sagepub.com/doi/10.1177/27551938231221509">noncash depreciation cuts into their profits</a>. Those expenses, which show up only in accounting ledgers, assume that assets such as equipment and facilities are gradually decreasing in value and ultimately will need to be replaced.</p>
<p>That might be reasonable if the chains purchased new items once their value depreciated to zero, but that is not always true. <a href="https://www.govinfo.gov/content/pkg/GOVPUB-Y3_M46_3-PURL-LPS49906/pdf/GOVPUB-Y3_M46_3-PURL-LPS49906.pdf">A 2004 report</a> by the Medicare Payment Advisory Commission found that the depreciation claimed by health care companies, including nursing homes, may not reflect actual capital expenditures or the actual market value.</p>
<p>If disallowed expenses and noncash depreciation were not included, <a href="https://doi.org/10.1177/27551938231221509">profit margins for the nursing home industry would jump</a> to 8.8%, far more than the 3% it claims. And given that these numbers all come from nursing home cost reports submitted to the government, they may underestimate the profits even more. Audited cost reports are not required, and the <a href="https://www.gao.gov/assets/gao-16-700.pdf">Government Accountability Office has found</a> that CMS does little to ensure the numbers are correct and complete. </p>
<p>This lack of basic oversight essentially gives dishonest nursing home owners the power to grab more money from Medicare and Medicaid while being empowered to claim that their financials prove they need more.</p>
<p>“They face no repercussions,” Brooks of Consumer Voice said, commenting on the current state of nursing home operations and their unscrupulous owners. “That’s why these people are here. It’s a bonanza to them.”</p>
<p>Ultimately, experts say, finding ways to force nursing homes to provide quality care has remained elusive. Michael Gelder, former senior health policy adviser to then-Gov. Pat Quinn of Illinois, learned that brutal lesson in 2010 as head of a task force formed by Quinn to investigate nursing home quality. That group successfully pushed a new law, but Gelder now says his success failed to protect this country’s most vulnerable citizens.</p>
<p>“I was perhaps naively convinced that someone like myself being in the right place at the right time with enough resources could really fix this problem,” he said. “I think we did the absolute best we could, and the best that had ever been done in modern history up to that point. But it wasn’t enough. It’s a battle every generation has to fight.”</p>
<p><em><a href="https://theconversation.com/how-for-profit-nursing-home-regulators-can-use-the-powers-they-already-have-to-fix-growing-problems-with-poor-quality-care-225053">Click to learn more about how some existing tools</a> can address problems with for-profit nursing homes.</em></p><img src="https://counter.theconversation.com/content/225045/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Campbell is an adjunct assistant professor at Columbia University and a contributing writer at the Garrison Project, an independent news organization that focuses on mass incarceration and criminal justice.</span></em></p><p class="fine-print"><em><span>Harrington is an advisory board member of the nonprofit Veteran's Health Policy Institute and a board member of the nonprofit Center for Health Information and Policy. Harrington served as an expert witness on nursing home litigation cases by residents against facilities owned or operated by Brius and Shlomo Rechnitz in the past and in 2022. She also served as an expert witness in a case against The Citadel Salisbury in North Carolina in 2021.
</span></em></p>Owners of midsize nursing home chains drain billions from facilities, hiding behind opaque accounting practices and harming the elderly as government, which has the power to stop it, falls short.Sean Campbell, Investigative journalist, The ConversationCharlene Harrington, Professor Emeritus of Social Behavioral Sciences, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2250532024-03-14T12:46:04Z2024-03-14T12:46:04ZHow for-profit nursing home regulators can use the powers they already have to fix growing problems with poor-quality care<figure><img src="https://images.theconversation.com/files/579738/original/file-20240304-22-wj7pxu.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5760%2C3837&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nursing homes care for more than a million people in the U.S.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/NursingHomeHigh/7c838b5ffe0a4558bde70f78d42f123e/photo">AP Photo/Richard Drew</a></span></figcaption></figure><p>Governments at both state and federal levels have <a href="https://doi.org/10.1093/ppar/prad001">yet to fully wield their authority</a> to fight poor-quality care at for-profit nursing homes nationwide, leaving the pressing need for elder care accountability unmet.</p>
<p>Medicare has the <a href="https://doi.org/10.1093/ppar/prad001">power to improve financial accountability</a> at nursing facilities by capping profits while requiring that a percentage of revenues be spent on direct care expenditures. Already, four states – New Jersey, New York, Massachusetts and Pennsylvania – <a href="https://doi.org/10.1093/ppar/prad001">have shown this can be done</a>, passing laws requiring minimum percentages of expenditures on direct care while limiting profits.</p>
<p>I am a <a href="https://profiles.ucsf.edu/charlene.harrington">behavioral scientist</a> at the University of California, San Francisco who studies the economics of nursing homes and the implications for care. I am also the co-author of an <a href="https://theconversation.com/for-profit-nursing-homes-are-cutting-corners-on-safety-and-draining-resources-with-financial-shenanigans-especially-at-midsize-chains-that-dodge-public-scrutiny-225045">investigative piece in The Conversation</a> about for-profit nursing homes.</p>
<p>States also have the power to suspend and disqualify nursing home owners from the Medicaid program when they provide poor-quality care, commit fraud or harm residents. </p>
<p>For example, after the New Jersey comptroller <a href="https://www.cbsnews.com/newyork/news/princeton-care-center-abrupt-closure-law-violation/">concluded that the abrupt closure</a> of the Princeton Care Center nursing home in September 2023 jeopardized the health and safety of residents, the state took action. It <a href="https://nj.gov/comptroller/news/2024/20240116.shtml#:%7E:text=The%20Office%20of%20the%20State,other%20Medicaid%2Dfunded%20nursing%20homes.">moved in January 2024 to impose an eight-year ban</a> on the owners’ ability to receive Medicaid reimbursement at any nursing home and to require them to divest themselves from <a href="https://nj.gov/comptroller/news/2024/20240116.shtml#:%7E:text=The%20Office%20of%20the%20State,other%20Medicaid%2Dfunded%20nursing%20homes.">two other facilities they already ran</a>.</p>
<p>The federal government can also take aggressive actions to force the industry to shape up, even without new legislation. A 2023 <a href="https://scholarship.law.wm.edu/cgi/viewcontent.cgi?article=4001&context=wmlr">law review article</a> demonstrates that state and federal governments could use state licensure laws and federal nursing home certification requirements to prevent abuse. The article argues that governments could set clear nursing home ownership and operation criteria for individuals and companies, which can include experience, expertise, reputation, past performance and financial solvency standards.</p>
<p>Even federal prosecutors have largely unused powers to crack down on the industry. The Department of Justice <a href="https://www.justice.gov/opa/pr/department-justice-launches-national-nursing-home-initiative">has taken actions</a> against many nursing home owners and chains but rarely has moved to remove the certification of facilities despite having the authority to do so. Instead, nursing homes subject to legal action by the department generally are placed under what is known as a corporate integrity agreement and assigned a monitor to oversee regulatory compliance.</p>
<p>For example, <a href="https://oig.hhs.gov/fraud/cia/agreements/Saber_Healthcare_Holdings_LLC_et_al_03312020.pdf">Saber Healthcare Holdings</a>, which owned <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">126 nursing homes</a> in 2024, was placed under a <a href="https://oig.hhs.gov/faqs/corporate-integrity-agreement-faq/">corporate integrity agreement</a> in 2021. </p>
<p>The question remains: Why haven’t governments fully flexed their existing regulatory muscles to enforce vital reforms in nursing homes? With the welfare of vulnerable residents at stake, the urgency for decisive action has never been clearer.</p>
<p><em><a href="https://theconversation.com/for-profit-nursing-homes-are-cutting-corners-on-safety-and-draining-resources-with-financial-shenanigans-especially-at-midsize-chains-that-dodge-public-scrutiny-225045">Read The Conversation’s investigation</a> to learn more about the nation’s for-profit nursing homes and how they’re cutting corners on safety.</em></p><img src="https://counter.theconversation.com/content/225053/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harrington is a advisory board member of the nonprofit Veteran's Health Policy Institute and a board member of the nonprofit Center for Health Information and Policy. Harrington served as an expert witness on nursing home litigation cases by residents against facilities owned or operated by Brius and Shlomo Rechnitz in the past and in 2022. She also served as an expert witness in a case against The Citadel Salisbury in North Carolina in 2021.
</span></em></p>Governments can do more to protect patients at for-profit nursing homes. A behavioral scientist who studies nursing homes weighs in.Charlene Harrington, Professor Emeritus of Social Behavioral Sciences, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2172642024-01-28T19:05:20Z2024-01-28T19:05:20ZMedicare turns 40: since 1984 our health needs have changed but the system hasn’t. 3 reforms to update it<figure><img src="https://images.theconversation.com/files/571353/original/file-20240125-29-9x8icz.jpg?ixlib=rb-1.1.0&rect=0%2C57%2C7719%2C4513&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/selective-focus-photography-of-assorted-color-balloons-Hli3R6LKibo">Ali Goldstein/Unsplash</a></span></figcaption></figure><p>Forty years ago, Medicare as we know it today was born. It was the reincarnation of the Whitlam government’s Medibank, introduced in 1975 but <a href="https://www.sciencedirect.com/science/article/abs/pii/0277953684902661">dismantled</a> in stages by the Fraser Liberal government. </p>
<p>Medibank was developed in the 1960s by health economists <a href="https://grattan.edu.au/news/remebering-richard-scotton-co-founder-of-medicare/">Dick Scotton</a> and <a href="https://openresearch-repository.anu.edu.au/bitstream/1885/159512/1/Daring_to_Dream.pdf">John Deeble</a>, when disease prevalence was different and the politics of reform were diabolical. </p>
<p>But the nation has changed since 1984, and so have our health needs. Medicare is now struggling to ensure the access to health care for millions of Australians we were once promised. </p>
<p>Let’s look at how we got here – and three radical changes we need to keep the Medicare promise into the future: making it cheaper to see a GP; paying less for blood and imaging tests; and covering dental care. </p>
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Read more:
<a href="https://theconversation.com/if-you-live-in-a-bulk-billing-desert-its-hard-to-see-a-doctor-for-free-heres-how-to-fix-this-204029">If you live in a bulk-billing ‘desert’ it's hard to see a doctor for free. Here's how to fix this</a>
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<h2>Free hospital care, but you might pay to see a GP</h2>
<p>One of my first jobs in the health system, in the days before Medicare and Medibank, was acting in charge of revenue collection for three public hospitals. A small subset of people could get free, albeit stigmatised, care. </p>
<p>We had bad debts, because some people couldn’t afford to pay their hospital bills and I was allowed by policy to recommend that some be written off. But for others I had to seek court authorisation to seize their wages to pay off their hospital debt. </p>
<p>Medibank changed that. Now all Australians can get public hospital care without any financial barrier.</p>
<figure class="align-center ">
<img alt="Doctor draws blood from patient" src="https://images.theconversation.com/files/571350/original/file-20240125-19-xmbtth.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/571350/original/file-20240125-19-xmbtth.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/571350/original/file-20240125-19-xmbtth.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/571350/original/file-20240125-19-xmbtth.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/571350/original/file-20240125-19-xmbtth.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/571350/original/file-20240125-19-xmbtth.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/571350/original/file-20240125-19-xmbtth.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Before Medicare and Medibank, patients often faced hospital care debts.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/a-woman-laying-in-a-hospital-bed-next-to-a-man-dkZQfm1LLQE">National Cancer Institute/Unsplash</a></span>
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<p>But the financial barriers to seeing a GP or a private specialist (out of hospital) have remained. Doctors continue to charge what they like, with Medicare often only covering a portion of their fees. This has left many patients facing significant out-of-pocket payments.</p>
<p>When Medicare was designed, medical care was provided mostly by solo medical practitioners working in practices they owned. It was a one-to-one professional relationship, with the patient paying the practitioner for each service. </p>
<p>Over time, general practice evolved into group practices organised as partnerships. Next, they <a href="https://onlinelibrary.wiley.com/doi/10.5694/mja2.51038">consolidated and corporatised</a>. A handful of corporates now provide all <a href="https://www.accc.gov.au/system/files/public-registers/documents/ACL%20Healius%20%20-%20Statement%20of%20Issues.pdf">private pathology</a> (which tests blood and other tissues) and <a href="https://www.jacr.org/article/S1546-1440(07)00614-X/fulltext">radiology</a> (which provides imaging services) and a large proportion of GP care. </p>
<p>Corporates have not made the same inroads into most other specialties. But since the 1980s, states have reduced public hospital outpatient services. So patients are now more reliant on private medical specialists for care referred by their GP.</p>
<h2>Much has changed, but cost of living pressures remain</h2>
<p>Health-care needs have changed. As we live longer, we live with more diseases, many of which are chronic. The care required increasingly involves many different health providers and includes non-medical specialties such as podiatry, physiotherapy and psychology. </p>
<p>When Medicare was introduced, university education was offered for only a few of these professions. But their training has evolved and so too what they can do. This is particularly the case for nursing. It has evolved from an apprenticeship model to a profession with its own specialties. A subset – nurse practitioners – have the authority to diagnose and prescribe medication.</p>
<p>Broader technology trends have also had an impact on health care, as with all other sectors. Virtual care and telehealth <a href="https://theconversation.com/what-can-you-use-a-telehealth-consult-for-and-when-should-you-physically-visit-your-gp-135046">proved their worth</a> during the early years of the COVID pandemic, just as generative AI is beginning to show its promise now.</p>
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Read more:
<a href="https://theconversation.com/ai-can-help-detect-breast-cancer-but-we-dont-yet-know-if-it-can-improve-survival-rates-210800">AI can help detect breast cancer. But we don't yet know if it can improve survival rates</a>
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<p>Medicare was first and foremost about efficiently removing financial barriers to access. It was introduced as part of an <a href="https://www.jstor.org/stable/20635272">agreement with the Labor movement</a> about reducing costs of living and, in particular, ensuring people could attend a doctor without having to worry about how they would pay for the visit.</p>
<p>However, <a href="https://www.abs.gov.au/statistics/health/health-services/patient-experiences/2022-23#data-downloads">about 1.2 million Australians</a> deferred or missed out on seeing a GP because of cost in the 2022-23 financial year. Lower-income Australians have higher rates of missing out on care. </p>
<p>Medical fees aren’t regulated and so consumers face a lottery – not knowing whether a fee will be charged and having no control over that decision. Only about 52% of all Australians were <a href="https://www.health.gov.au/sites/default/files/2023-08/medicare-statistics-per-patient-bulk-billing-dashboard-2022-23.pdf">always bulk-billed</a> in 2022-23, down from 66% a year earlier. </p>
<p>So how can we get Medicare back on track towards its goal of universal health care for all Australians? Here are three radical reforms we should prioritise. </p>
<h2>1. Make GP care affordable for all</h2>
<p>Rebates are currently subject to political whim. The Liberal government (in office from 2013 to 2022) froze rebates, leading to increases in average out-of-pocket payments and reduced bulk-billing.</p>
<p>The first step in reducing costs as a barrier to GP care should be introduction of independent fee-setting. </p>
<p>Canadian Medicare – which was the model for Australia’s system – mostly has <a href="https://journals.sagepub.com/doi/full/10.1177/0840470421994304">no out-of-pocket payments</a>. Fees are set by negotiations, not politicians’ whims, and this is <a href="https://laws-lois.justice.gc.ca/eng/acts/C-6/page-1.html#h-151558">enshrined in legislation</a>. </p>
<p>With independent fee-setting in place, a new scheme of “participating providers” should be introduced. Under such a scheme, practices would bulk-bill everyone, and participate in agreed quality-improvement programs.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/what-if-medicare-was-restricted-to-gps-who-bulk-billed-this-kind-of-reform-is-possible-203543">What if Medicare was restricted to GPs who bulk billed? This kind of reform is possible</a>
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<p>If fees are set independently and fairly, extra billing over and above the fee is unjustifiable. Non-participating practices would not be eligible for Medicare benefits. </p>
<p>It’s anticipated the vast majority of practices would agree to participate. In Canada, the participation rate is roughly 100%, and bulk billing in Australia is <a href="https://www.health.gov.au/resources/publications/medicare-quarterly-statistics-bulk-billing-by-primary-health-network-september-quarter-2023-24">still over 75%</a>.</p>
<p>Participating practices should also be eligible for additional grants to employ other health professionals to provide a more comprehensive range of services – such as physiotherapists and psychologists – to meet the contemporary needs of a population with increasing chronic illness. </p>
<p>If successful, these changes would mean all Australians can access a GP and other primary care services without any out-of-pocket costs.</p>
<h2>2. Deal with diagnostics</h2>
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<img alt="Blood vials" src="https://images.theconversation.com/files/571360/original/file-20240125-25-3sefgm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/571360/original/file-20240125-25-3sefgm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/571360/original/file-20240125-25-3sefgm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/571360/original/file-20240125-25-3sefgm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/571360/original/file-20240125-25-3sefgm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/571360/original/file-20240125-25-3sefgm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/571360/original/file-20240125-25-3sefgm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The cost of processing tests varies.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/green-pink-and-purple-plastic-bottles-0jE8ynV4mis">Testalize.me/Unsplash</a></span>
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<p>Despite the evolution of ownership and market structures, pathology and radiology services are still reimbursed by fees for each service (with complex rules about rebates when multiple tests are performed simultaneously). </p>
<p>But while both industries are expensive to set up and buy or lease equipment, the cost of processing an additional test or image is low and sometimes close to zero. This means Medicare pays pathology and radiology providers much more than the tests or images cost.</p>
<p>Both industries are also ripe for further technological change, with the quality of generative AI rapidly improving, and costs likely to further reduce.</p>
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Read more:
<a href="https://theconversation.com/blood-money-pathology-cuts-can-reduce-spending-without-compromising-health-54834">Blood money: pathology cuts can reduce spending without compromising health</a>
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<p>The uncapped fee-for-service model for pathology and radiology needs to be replaced by one in which the benefits of technological change are shared between shareholders and taxpayers, rather than all accruing to the former. </p>
<p>This could be done by replacing fee-for-service payments with a payment model used in the corporate world. Private and public providers could be <a href="https://grattan.edu.au/report/blood-money-paying-for-pathology-services/">invited to tender</a> to provide these services in certain areas, with conditions around geographic access, quality and no out-of-pocket payments for consumers. </p>
<p>The same model could also apply to other technology-intensive types of health care, such as radiotherapy for cancer.</p>
<p>These changes might be cost-neutral for government, and save consumers the $24 they currently pay out of pocket on every pathology test that is not currently bulk-billed and $122 on each non-bulk-billed diagnostic imaging test.</p>
<h2>3. Cover dental care too</h2>
<figure class="align-center ">
<img alt="Boy undergoes dental treatment" src="https://images.theconversation.com/files/571358/original/file-20240125-19-wcmr9t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/571358/original/file-20240125-19-wcmr9t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/571358/original/file-20240125-19-wcmr9t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/571358/original/file-20240125-19-wcmr9t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/571358/original/file-20240125-19-wcmr9t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/571358/original/file-20240125-19-wcmr9t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/571358/original/file-20240125-19-wcmr9t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Dental care is largely unaffordable.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/boy-in-blue-long-sleeve-shirt-drinking-from-a-feeding-bottle-loBRFqXm1QA">Lafayett Zapata Montero/Unsplash</a></span>
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<p>A major omission from Medicare from the start, and a source of continuing inequity, is oral health care. More than two million Australians <a href="https://www.abs.gov.au/statistics/health/health-services/patient-experiences/2022-23#data-downloads">missed out</a> on oral health care because of cost in 2022-23.</p>
<p>A new scheme to <a href="https://grattan.edu.au/report/filling-the-gap/">slowly expand universal protection</a> against the costs of oral health care should be phased in over the next decade. This would eventually mean all preventive and basic dental care would be available for everyone, with no out-of-pocket payments. </p>
<p>This would require a parallel expansion of the oral health workforce (dentists and <a href="https://www.dentalboard.gov.au/Registration/Oral-Health-Therapist.aspx">oral health therapists</a>) and development of new payment models based on a participating practice model rather than simply introducing another unregulated schedule of oral health fees paid via Medicare.</p>
<p>Innovation <a href="https://www.health.gov.au/sites/default/files/2023-12/nhra-mid-term-review-final-report-october-2023.pdf">needs to be built into the Australian health system</a>. However, the foundations for innovation must be based on Medicare’s founding principles of addressing financial barriers to provide universal and equitable health care to all Australians. </p>
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Read more:
<a href="https://theconversation.com/expensive-dental-care-worsens-inequality-is-it-time-for-a-medicare-style-denticare-scheme-207910">Expensive dental care worsens inequality. Is it time for a Medicare-style 'Denticare' scheme?</a>
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<img src="https://counter.theconversation.com/content/217264/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Duckett, like all Australians, benefits from Medicare.</span></em></p>The health care world has changed a lot in 40 years, but Medicare hasn’t. Here are three areas for radical forms to the system that will achieve its aims of universal health care for all Australians.Stephen Duckett, Honorary Enterprise Professor, School of Population and Global Health, and Department of General Practice, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2179142023-11-30T07:18:00Z2023-11-30T07:18:00ZReform delay causes dental decay. It’s time for a national deal to fund dental care<p>A <a href="https://parlinfo.aph.gov.au/parlInfo/download/committees/reportsen/RB000078/toc_pdf/AsystemindecayareviewintodentalservicesinAustralia.pdf">Senate committee</a> has investigated why so many Australians are missing out on dental care and made 35 recommendations for reform. </p>
<p>By far the most sweeping is the call for universal coverage for essential dental care. The committee also proposed a suite of measures to get more dental care to groups who are missing out, including those in rural areas. </p>
<p>The government has three months to respond. It should lay out a plan to gradually expand coverage, while putting guardrails in place to make sure care is effective, efficient and equitable. </p>
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Read more:
<a href="https://theconversation.com/expensive-dental-care-worsens-inequality-is-it-time-for-a-medicare-style-denticare-scheme-207910">Expensive dental care worsens inequality. Is it time for a Medicare-style 'Denticare' scheme?</a>
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<h2>If Australians can’t pay, they miss out</h2>
<p>The <a href="https://parlinfo.aph.gov.au/parlInfo/download/committees/reportsen/RB000078/toc_pdf/AsystemindecayareviewintodentalservicesinAustralia.pdf">Senate committee report</a> follows <a href="https://parlinfo.aph.gov.au/parlInfo/download/committees/reportsen/RB000080/toc_pdf/Interimreport.pdf">more than a dozen</a> national inquiries and reports into dental care since 1998, many with similar findings.</p>
<p>Dental care was left out of Medicare from the start, due to opposition from dentists and <a href="https://johnmenadue.com/why-dental-care-was-excluded-from-medicare-and-why-it-should-now-be-included-an-edited-repost/">concerns</a> about cost. </p>
<p>Half a century later, Australia still funds oral health very differently to how we fund care for the rest of the body, with patients paying most of the cost themselves. </p>
<p>As a result, many people miss out on care. In <a href="https://www.abs.gov.au/statistics/health/health-services/patient-experiences/latest-release">2022-23</a>, 2.3 million Australians skipped or delayed necessary dental care because of the cost – 17.6% of people, up from 16.4% the year before.</p>
<p>People on lower incomes were much more likely to miss out. People living in the poorest areas are around three times as likely to wait more than two years between visits to the dentist, compared to people in the wealthiest areas. One in four report delaying care. </p>
<p>Even if you can afford to see a dentist, you might not be able to get in. Our analysis of census data shows there is one dentist for every 400 to 500 people in inner-city parts of most capital cities. But in Blacktown North in outer Sydney, there is only one dentist for every 5,100 people. </p>
<p>Regional areas fare even worse. There is only one for every 10,300 people in the northeast of Ballarat in Victoria. In some remote areas, there are no working dentists at all.</p>
<h2>Missing dental care can affect the whole body</h2>
<p>The consequences of missing dental care are serious. Around 80,000 hospital <a href="https://www.aihw.gov.au/reports/dental-oral-health/oral-health-and-dental-care-in-australia/contents/hospitalisations">visits</a> a year are for preventable dental conditions. </p>
<p>Oral health problems are also <a href="https://www.aihw.gov.au/reports/dental-oral-health/oral-health-and-dental-care-in-australia/contents/introduction">linked</a> to a range of chronic diseases affecting the rest of the body too, and may cause <a href="https://thenewdaily.com.au/life/2023/07/15/gum-disease-shrinks-your-brain/">damage</a> to the brain. </p>
<p>On top of that, there are costs from people not being able to work or study, leading to further economic costs of more than <a href="https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/j.1834-7819.2012.01718.x">half a billion</a> dollars a year. </p>
<p>Those numbers only hint at the individual suffering involved. Dental disease often means pain, embarrassment and stigma. </p>
<p>The Senate inquiry heard from one 30-year-old on a low income who couldn’t afford dental care for years. They skipped meals for months to save up enough money to go to the dentist, and were finally diagnosed with advanced gum disease. They now expect to lose teeth, which will affect them for the rest of their life.</p>
<h2>Dental problems are rising, spending is falling</h2>
<p>Compared to five years ago, more of us have untreated dental decay, are concerned about the appearance of our teeth, avoid food due to dental problems, and have toothaches. </p>
<p>Despite all this, government spending on dental health has been <a href="https://www.aihw.gov.au/getmedia/52d76196-5884-479c-93e5-12a17afbb2bb/aihw_den_231_costs_datatables_oralhealthanddentalcareinaustralia_tranche_6_17032023_1.xlsx.aspx">falling</a>. In the ten years to 2020-21, the federal government’s share of spending on dental services – excluding premium rebates – fell from 12% to 5%, while the states’ share fell from 10% to 9%.</p>
<p>Federal government spending on private health insurance rebates for dental care increased, but that doesn’t close the funding gap, and it doesn’t help the most vulnerable.</p>
<h2>Time for universal dental care</h2>
<p>Most submissions to the Senate inquiry supported major reform to expand coverage for dental care, as previous <a href="https://apo.org.au/sites/default/files/resource-files/2009-07/apo-nid17921.pdf">reviews</a>, <a href="https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf">Royal Commissions</a> and a 2019 Grattan Institute <a href="https://grattan.edu.au/wp-content/uploads/2019/03/915-Filling-the-gap-A-universal-dental-scheme-for-Australia.pdf">report</a> have recommended. </p>
<p>Getting there will be costly. </p>
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Read more:
<a href="https://theconversation.com/worried-about-your-childs-teeth-focus-on-these-3-things-212870">Worried about your child's teeth? Focus on these 3 things</a>
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<p>The May <a href="https://budget.gov.au/content/bp2/download/bp2_2023-24.pdf">budget</a> kicked the can down the road by extending the current, inadequate funding for public dental services for another year. That funding will now stop in mid-2025, the same time that federal and state governments need to agree on a new National Health Reform Agreement – the biggest financial health deal in Australia.</p>
<p>With national health funding up in the air, there is an opportunity to finally work out a plan to expand dental coverage, starting in less than two years. </p>
<h2>Phasing, fairness and efficiency will be key</h2>
<p>Building a new, universal health care system is something Australia hasn’t done for generations. It will take more than simply expanding funding. Instead, governments should seize an historic opportunity to avoid the <a href="https://grattan.edu.au/wp-content/uploads/2022/12/A-new-Medicare-strengthening-general-practice-Grattan-Report.pdf">problems</a> in other universal coverage schemes. </p>
<p>First, dental coverage should ramp up gradually. The Senate committee <a href="https://parlinfo.aph.gov.au/parlInfo/download/committees/reportsen/RB000078/toc_pdf/AsystemindecayareviewintodentalservicesinAustralia.pdf">recommended</a> phasing in a universal scheme, and mentioned establishing a Seniors Dental Benefit Scheme, and expanding the Child Dental Benefits Schedule to cover all children over time. </p>
<p>Starting with these steps would allow time for the workforce, providers, and government funding to expand to care for more people, as Australia builds a universal scheme.</p>
<p>Second, policies should ensure care is available where it’s needed most. This means getting more dentists in <a href="https://content.vu.edu.au/sites/default/files/media/is-medicare-fair-cities-and-country-mitchell-institute.pdf">disadvantaged</a> and rural areas.</p>
<p>Even with more funding and broader coverage, some areas will struggle to attract dentists, particularly where there is a small population, few people who can afford fees and where clinics need to be set up from scratch. </p>
<p>The committee proposed incentives for providers in rural areas, new dental schools in regional universities, expanding rural medical student subsidies to dentistry and oral health, and better pay for clinicians in public dental clinics.</p>
<p>Third, given the <a href="https://www.pbo.gov.au/sites/default/files/2023-11/For%20publication%20PR-2023-367-Various%20policy%20options%20for%20reforming%20Commonwealth%20subsidies%20of%20dental%20services%20-%20PRR_0.pdf">huge costs</a> involved, care must be efficient and effective. The committee outlined some ways to get good value for money. It said the universal scheme should fund essential oral health care, which would exclude cosmetic dentistry, for example. And it wants regulations and funding changed so oral health therapists can do more. </p>
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Read more:
<a href="https://theconversation.com/collaborating-with-communities-delivers-better-oral-health-for-indigenous-kids-in-rural-australia-141038">Collaborating with communities delivers better oral health for Indigenous kids in rural Australia</a>
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<p>Governments and the public should also be able to see where the billions of dollars of new investment are going, and the difference it is making. </p>
<p>Participating public and private clinics should record the treatments they provide, how satisfied their patients are, wait times and their results. And clinics should commit to following evidence-based guidelines and using data to continually improve their care. </p>
<p>Successive governments have skimped on dental care even as demand has risen. But those savings are a false economy that causes unnecessary disease and entrenches inequality. Today’s proposal for an overhaul should be the last – it’s time to fill this gap in the health system.</p><img src="https://counter.theconversation.com/content/217914/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Breadon's employer, Grattan Institute, has been supported in its work by government, corporates, and philanthropic gifts. A full list of supporting organisations is published at <a href="http://www.grattan.edu.au">www.grattan.edu.au</a>.</span></em></p><p class="fine-print"><em><span>Anika Stobart does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Access to dental care in Australia is worse than ever and is simply unaffordable to many.Peter Breadon, Program Director, Health and Aged Care, Grattan InstituteAnika Stobart, Senior Associate, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2126202023-09-06T20:13:15Z2023-09-06T20:13:15ZIt can be tough getting a GP appointment. Nurse practitioners could take some of the load<figure><img src="https://images.theconversation.com/files/546330/original/file-20230905-29-jl68t8.jpg?ixlib=rb-1.1.0&rect=0%2C131%2C5142%2C3291&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/KdWfhEwjcIE">Unsplash/Cezar Sampaio</a></span></figcaption></figure><p>Australians are living longer than ever. But these extra years of life come with higher rates of <a href="https://www.aihw.gov.au/reports/australias-health/chronic-conditions-and-multimorbidity">long-term and complex conditions</a> and greater health care needs. </p>
<p>The government wants to <a href="https://www.health.gov.au/sites/default/files/documents/2022/03/australia-s-primary-health-care-10-year-plan-2022-2032-future-focused-primary-health-care-australia-s-primary-health-care-10-year-plan-2022-2032.pdf">improve</a> Australians’ access to primary care services. These services would usually be delivered by a GP. But as part of this change, a new <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/unleashing-the-potential-for-our-health-workforce-review-appointment">review</a> is exploring how other health professionals could expand their current scope of work to meet growing needs. </p>
<p>Nurses make up <a href="https://www.aihw.gov.au/reports/workforce/health-workforce">more than 50%</a> of the health workforce and have untapped and under-used skills that would ease the skills gap in our health system. Within this group, <a href="https://www.acnp.org.au/aboutnursepractitioners">nurse practitioners</a> have advanced training and the potential to deliver more services than they’re currently allowed – without the oversight of a GP. </p>
<h2>How will access to primary care change?</h2>
<p>One of the big changes is that from October 2023, some patients will be able to register with one GP or general practice under the <a href="https://www.health.gov.au/our-work/mymedicare">MyMedicare</a> scheme. Those who are registered will start to have access to extra funded services like longer telehealth <a href="https://www.health.gov.au/our-work/mymedicare">appointments</a>. </p>
<p>The first patients who will get access to these benefits are people with multiple health conditions and/or additional social needs. Having one doctor who knows them, and their history, can connect them more seamlessly with all of the different health professionals and services. This saves <a href="https://pubmed.ncbi.nlm.nih.gov/31698168/">patients and carers</a> time, money and effort.</p>
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Read more:
<a href="https://theconversation.com/should-you-register-with-a-gp-what-is-mymedicare-and-how-might-it-change-the-care-you-get-206183">Should you register with a GP? What is MyMedicare and how might it change the care you get?</a>
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<p>For MyMedicare to work, Australia will need more health professionals with the right skills available in cities, regional towns and in rural and remote locations. </p>
<p>Currently, Australia is set to have a shortfall of 10,600 GPs by <a href="https://www.ama.com.au/articles/general-practitioner-workforce-why-neglect-must-end">2032</a>. This represents a serious problem. While steps are being taken to grow the GP <a href="https://insightplus.mja.com.au/2021/17/its-more-than-the-money-getting-gps-to-go-rural/">workforce</a>, this takes time. And with a <a href="https://www.who.int/news/item/02-06-2022-global-strategy-on-human-resources-for-health--workforce-2030">worldwide</a> health workforce shortage, it will not be easy. </p>
<p>Australia will need to find other solutions. One option is to look to nurses to take on tasks for which they are suitably skilled but have historically been undertaken by doctors. </p>
<h2>How nurses can help</h2>
<p>In the United Kingdom, the United States, The Netherlands and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5020757/">Canada</a>, advanced nursing – where nurses have postgraduate education and training to take on more specialised tasks and roles – has been relied on for years. </p>
<p>At the most advanced level of nursing, a nurse practitioner is a trained registered nurse who provides advanced nursing care either independently and autonomously, or with a doctor. Nurse practitioners can assess and diagnose health problems, order and interpret diagnostic tests, prescribe medicines, <a href="https://www.acnp.org.au/np-fact-sheets">refer</a> patients to other health professionals and even admit them to hospitals. </p>
<p>Nurse practitioners have been practising in Australia since 2000, starting in emergency care, with <a href="https://hwd.health.gov.au/resources/publications/factsheet-nrpr-2019.pdf">more than 1,400</a> practising in total in Australia by 2019. However, unlike other countries, Australian nurse practitioners must work in collaboration with a doctor. If they were to practise more independently, nurse practitioners could expand health-care access for thousands of Australians, including those living in rural and remote areas. </p>
<p>A recent NSW Health report presented a framework for specialised rural nurse practitioners that shows how care might be provided to focus on local community <a href="https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2022_057.pdf">needs</a>. For people living with a disability, or chronic and complex conditions, nurse practitioners can provide services in their communities, such as diagnosis, treatment plans, dialysis and make referrals to a specialist, including via telehealth. This could reduce the need for long-distance travel or a long wait time to access a GP. </p>
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<h2>Don’t we have a shortage of nurses?</h2>
<p>It is true, nurses are leaving the workforce in the thousands. One fifth of nurses in Australia intend to leave nursing in the next <a href="https://www.mckinsey.com/industries/healthcare/our-insights/should-i-stay-or-should-i-go-australias-nurse-retention-dilemma">12 months</a>. Keeping them requires better working <a href="https://researchers.mq.edu.au/en/publications/workplace-stress-and-resilience-in-the-australian-nursing-workfor">conditions</a>.</p>
<p>But it’s not just about reducing burnout, stress and workloads. Nurses want career development, the opportunity to extend their scope of practice with advanced training, and for these complex care skills to be recognised and <a href="https://www.acn.edu.au/wp-content/uploads/white-paper-optimising-advanced-practice-nursing.pdf">used</a>. </p>
<p>Access to opportunities for career development and progression is a key driver of nurse <a href="https://www.nswnma.asn.au/wp-content/uploads/2023/02/Impacts-of-COVID-19-and-workloads-on-NSW-nurses-and-midwives-mental-health-and-wellbeing_final.pdf">retention</a>. </p>
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Read more:
<a href="https://theconversation.com/how-do-you-fix-general-practice-more-gps-wont-be-enough-heres-what-to-do-195447">How do you fix general practice? More GPs won't be enough. Here's what to do</a>
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<h2>Why haven’t nurse practitioners already solved the workforce crisis?</h2>
<p>Nurse practitioners are registered nurses who have additional postgraduate education and clinical training in their speciality area. </p>
<p>Nurse practitioners are currently required to work in collaboration with a doctor to deliver care, which limits the extent to which they can resolve the workforce gaps we face. A nurse practitioner can prescribe medications, for example, but must do so with oversight via a sign-off from a <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/midwives-nurse-pract-qanda-nursepract#4">doctor</a>. </p>
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<img alt="Male nurse takes a woman's blood pressure" src="https://images.theconversation.com/files/546328/original/file-20230905-27-mvp0l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/546328/original/file-20230905-27-mvp0l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=903&fit=crop&dpr=1 600w, https://images.theconversation.com/files/546328/original/file-20230905-27-mvp0l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=903&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/546328/original/file-20230905-27-mvp0l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=903&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/546328/original/file-20230905-27-mvp0l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1135&fit=crop&dpr=1 754w, https://images.theconversation.com/files/546328/original/file-20230905-27-mvp0l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1135&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/546328/original/file-20230905-27-mvp0l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1135&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">Nurse practitioners in Australia currently need a doctors’ oversight to prescribe medications.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/7uSvaBY69d0">Unsplash/CDC</a></span>
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<p>The federal government’s <a href="https://www.health.gov.au/sites/default/files/2023-05/nurse-practitioner-workforce-plan.pdf">nurse practitioner workforce plan</a> aims to remove barriers to patients accessing a nurse practitioner. The plan is looking at whether nurse practitioners should provide Medicare-funded services, create additional nurse-led care items and remove the requirement for them to collaborate with doctors in delivering care.</p>
<p>The federal government’s current proposals may therefore see nurse practitioners working completely independently, in a similar way to that overseas.</p>
<p>But despite evidence showing nurse practitioners <a href="https://www.sciencedirect.com/science/article/pii/S1555415513004108?casa_token=7ye49Vc_XLMAAAAA:hw76-d1CjqvF-jBZ-7D_y9_DOAJzeMhav979UgBq1WOxnCdI7QfKoYPcLXxj98bZ2wjHqQQ7qw">provide safe health care</a>, the proposal has been met with <a href="https://www.racgp.org.au/FSDEDEV/media/documents/RACGP/Reports%20and%20submissions/2019/RACGP-submission-MBS-Review-Nurse-Practitioners-Reference-Group.pdf">concern</a> from some doctors that increased independence may risk patient safety and lead to more fragmented care. They also argue it would be unfair for patients who can’t see a doctor and who must see a nurse practitioner instead. </p>
<h2>What should happen next?</h2>
<p>Delivering better quality primary health care in Australia ultimately means we need to make better use of our health services and align it with our changing population needs. </p>
<p>To achieve this, we will need to grow our nurse practitioner workforce and use them more effectively. Enabling nurse practitioners to use all their skills independently might also help to stem the loss of nursing workforce.</p>
<p>But expanding the scope of any profession must be done in a way that improves collaboration, team-based working and patient-centred care. Health care is safest and most effective when health professionals work together – and with patients – to make decisions about care. So it’s important for the plan to include incentives that make collaboration more likely between nurse practitioners and doctors.</p>
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Read more:
<a href="https://theconversation.com/pharmacists-should-be-able-to-work-with-gps-to-prescribe-medicines-for-long-term-conditions-212359">Pharmacists should be able to work with GPs to prescribe medicines for long-term conditions</a>
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<img src="https://counter.theconversation.com/content/212620/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Reema Harrison receives funding from National Health and Medical Research Council, Medical Research Futures Fund, Cancer Institute NSW, Australian Research Council, Medibank Better Health Fund, and NSW Health. </span></em></p><p class="fine-print"><em><span>Laurel Mimmo works for a NSW Health organisation and is a member of the NSW Nurses and Midwives Association, the Health Services Union and the Australian College of Nursing. She does not currently receive funding from any organisation. </span></em></p>Nurses make up more than 50% of the health workforce and have untapped and under-used skills that could ease the skills gap in our health system.Reema Harrison, Associate Professor, Macquarie UniversityLaurel Mimmo, Honorary Post-doctoral Fellow, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2125032023-08-30T23:01:53Z2023-08-30T23:01:53ZMedicare starts a long road to cutting prices for drugs, starting with 10 costing it $50.5 billion annually – a health policy analyst explains why negotiations are promising but will take years<figure><img src="https://images.theconversation.com/files/545372/original/file-20230829-23-kg9w8p.jpg?ixlib=rb-1.1.0&rect=0%2C30%2C6720%2C4436&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Americans pay far more for prescription drugs compared with people in other high-income countries. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/sorting-weekly-medication-royalty-free-image/1190823309?adppopup=true">Willie B. Thomas/Digital Vision via Getty Images</a></span></figcaption></figure><p>The Biden administration released on Aug. 29, 2023, a <a href="https://www.cms.gov/files/document/fact-sheet-medicare-selected-drug-negotiation-list-ipay-2026.pdf">list of the first 10 drugs</a> that will be up for negotiations with pharmaceutical companies over their Medicare prices.</p>
<p>The drugs are purchased through <a href="https://www.medicare.gov/drug-coverage-part-d">Medicare Part D</a>, a prescription drug coverage program for Americans ages 65 and older. The 10 medications accounted for more than US$50.5 billion in gross costs between June 1, 2022, and May 31, 2023.</p>
<p>Provisions authorizing these negotiations were part of the <a href="https://www.irs.gov/inflation-reduction-act-of-2022">Inflation Reduction Act</a> which Congress passed in 2022, allowing Medicare to negotiate drug prices for the first time. Pending successful negotiations, these changes would amount to what researchers estimated to be net savings of about <a href="https://doi.org/10.18553/jmcp.2023.29.8.868">$1.8 billion in 2026</a>. The <a href="https://www.cbo.gov/system/files/2022-09/PL117-169_9-7-22.pdf">Congressional Budget Office projected an even bigger savings of $3.7 billion</a>.</p>
<p>The top 10 list includes such drugs as Johnson & Johnson’s <a href="https://www.xarelto-us.com/">Xarelto</a>, which treats blood clots, and Amgen’s <a href="https://www.enbrel.com/">Enbrel</a>, which treats rheumatoid arthritis and psoriasis.</p>
<p>Negotiations are expected to begin in October and continue until August 2024, with lower prices going into effect in 2026. </p>
<p>Democrats have <a href="https://www.cbsnews.com/news/inflation-reduction-act-drug-costs-medicare-seniors-cbs-news-explains/">hailed the new law’s drug pricing provisions as game-changing</a>. They’re likely to make the issue a centerpiece of their <a href="https://apnews.com/article/medicare-prescription-drug-negotiations-biden-inflation-2bf6775c3431111a2cd03fd033caefa7">2024 election campaigns</a>. Democrats are further emboldened as public opinion polls show <a href="https://www.kff.org/health-costs/poll-finding/kff-health-tracking-poll-december-2022/">overwhelming support for the policy among Americans</a>.</p>
<p>As a scholar who <a href="https://scholar.google.com/citations?user=QY68LSIAAAAJ&hl=en">researches the politics of health policy</a>, I’m skeptical that Medicare drug price negotiations will end up making as big a difference as Democrats have promised, at least in the near future. While U.S. prescription drug prices are excessive, the true potential of the policy is unclear, as it remains <a href="https://www.politico.com/news/2023/08/29/drugmakers-trade-groups-push-back-against-medicare-drug-price-negotiations-00111936">muddled in lawsuits</a> and <a href="https://www.biopharmadive.com/news/pharma-drug-pricing-negotiation-bill-ceo-response/628872/">industry opposition</a>. However, if it can withstand the ongoing attacks and become settled law, Americans ages 65 and up could see real financial relief down the line.</p>
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<h2>Cutting drug costs for Medicare enrollees</h2>
<p>The <a href="https://www.irs.gov/inflation-reduction-act-of-2022">Inflation Reduction Act</a> allows the Centers for Medicare & Medicaid Services to negotiate prices with the companies that make some of the most expensive drugs in the Medicare program, including life-saving cancer and diabetes treatments like <a href="https://www.imbruvica.com/">Imbruvica</a> and <a href="https://www.januvia.com/">Januvia</a>.</p>
<p>If the negotiations proceed as planned, the drug-price-negotiation provision is expected to <a href="https://www.cbo.gov/system/files/2022-09/PL117-169_9-7-22.pdf">save the U.S. government about $98.5 billion</a> by 2031 by allowing it to pay less on prescription drugs for Americans on Medicare – nearly <a href="https://medicareadvocacy.org/medicare-enrollment-numbers/#">66 million people</a>. The Biden administration hopes that these cost savings will be passed down to Americans 65 and older through <a href="https://www.kff.org/medicare/issue-brief/how-would-drug-price-negotiation-affect-medicare-part-d-premiums/">reduced Medicare Part D premiums</a> and lower out-of-pocket costs.</p>
<p>The Inflation Reduction Act provides <a href="https://theconversation.com/why-letting-medicare-negotiate-drug-prices-wont-be-the-game-changer-for-health-care-democrats-hope-it-will-be-188560">additional benefits for older Americans</a>, including limiting their out-of-pocket expenses for prescription drugs to no more than $2,000 annually, limiting the growth of Medicare Part D premiums, eliminating out-of-pocket costs for vaccines and providing premium subsidies to low-income people ages 65 and older.</p>
<p>The Inflation Reduction Act also includes a separate provision that requires drugmakers, under certain conditions, to <a href="https://www.cms.gov/files/document/fact-sheet-part-b-rebatable-drug-coinsurance-reduction.pdf">provide the Medicare program</a> with rebates if drug price increases outpace inflation, <a href="https://www.cms.gov/files/document/reduced-coinsurance-part-b-rebatable-drugs-apr-1-june-30.pdf">starting in January of 2023</a>. That measure is expected to <a href="https://www.cbo.gov/system/files/2022-07/senSubtitle1_Finance.pdf">yield $71 billion in savings</a> over a decade. </p>
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<img alt="A Black female pharmacist shows Black woman some prescription medications." src="https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.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">Government negotiations with pharmaceutical companies over drug pricing should lower medical costs for many people ages 65 and older.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/young-pharmacist-helping-a-senior-lady-choose-the-royalty-free-image/1352510394?adppopup=true">Marko Geber/DigitalVision via Getty Images</a></span>
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<h2>Penalties for companies that won’t negotiate</h2>
<p>The 10 drugs that the Centers for Medicare & Medicaid Services <a href="https://www.cms.gov/files/document/fact-sheet-medicare-selected-drug-negotiation-list-ipay-2026.pdf">have selected</a> accounted for $3.4 billion in out-of-pocket spending in 2022 <a href="https://www.cnbc.com/2023/08/29/10-drugs-to-face-medicare-price-negotiations-see-the-list.html">for Americans ages 65 and older</a> and $50.5 billion, or about 20%, of <a href="https://www.cms.gov/files/document/fact-sheet-medicare-selected-drug-negotiation-list-ipay-2026.pdf">total Part D gross prescription drug costs</a> from June 1, 2022, to May 31, 2023. </p>
<p>Pharmaceutical companies have to sign agreements to participate in the upcoming negotiations by October 2023. Based on criteria such as public feedback and consultation, as well as the clinical value of the drug, the Centers for Medicare & Medicaid Services will make an initial price offer in early 2024, with the potential to <a href="https://www.cms.gov/files/document/fact-sheetrevised-drug-price-negotiation-program-guidance-june-2023.pdf">further negotiate the price until August 2024</a>. Going forward, additional drugs will be subject to negotiations.</p>
<p>If drugmakers don’t negotiate, they will face stiff penalties in the form of a tax, reaching as high as <a href="https://www.kff.org/medicare/issue-brief/explaining-the-prescription-drug-provisions-in-the-inflation-reduction-act/#bullet02">95% of U.S. pharmaceutical product sales</a>. Alternatively, the companies may pull their drugs from the Medicare and Medicaid markets, meaning that seniors on Medicare would lose access to them.</p>
<h2>Why US drug prices are so high</h2>
<p><a href="https://www.healthsystemtracker.org/chart-collection/how-do-prescription-drug-costs-in-the-united-states-compare-to-other-countries/">Americans pay substantially more for prescription drugs</a> compared with people who live in countries with similar economies, like Germany, the U.K. and Australia. While Americans spent more than <a href="https://www.healthsystemtracker.org/chart-collection/how-do-prescription-drug-costs-in-the-united-states-compare-to-other-countries/">$1,100 a year</a> in 2019, Germans paid $825, the British paid $285 and Australians paid $434 per person.</p>
<p>The <a href="https://theconversation.com/why-the-us-has-higher-drug-prices-than-other-countries-111256">reasons for this disparity are multilayered</a> and include the overall <a href="https://theconversation.com/us-health-care-system-a-patchwork-that-no-one-likes-85252">complexity of the U.S. health care system</a> and the <a href="https://www.kff.org/other/report/follow-the-pill-understanding-the-u-s/">lack of transparency in the drug supply chain</a>. Of course, many other countries also directly <a href="https://theconversation.com/why-the-us-has-higher-drug-prices-than-other-countries-111256">set prices for drugs or use their monopoly on health services to drive down costs</a>.</p>
<p>For example, Dulera, an asthma drug, costs <a href="https://www.provista.com/blog/blog-listing/us-drug-prices-exceed-those-in-11-similar-countries">50 times more in the U.S.</a> than the international average. Januvia, a diabetes drug that is among the first 10 drugs up for price negotiation, and Combigan, a glaucoma drug, cost about <a href="https://www.cusd.com/Downloads/EBC_013020_US_v_Int_RX_Drug_Prices.pdf">10 times more</a>.</p>
<p>These costs impose a <a href="https://www.commonwealthfund.org/publications/journal-article/2018/nov/whats-driving-prescription-drug-prices-us">big burden on Americans</a> – <a href="https://www.commonwealthfund.org/publications/journal-article/2018/nov/whats-driving-prescription-drug-prices-us">1 in 5 of whom</a> skip at least some of their prescribed medications due to the expense. Those 65 and older are <a href="https://www.kff.org/health-costs/poll-finding/kff-health-tracking-poll-february-2019-prescription-drugs/">particularly affected</a> by these problems.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/545363/original/file-20230829-17-5vd6tm.jpg?ixlib=rb-1.1.0&rect=34%2C17%2C5657%2C3763&q=45&auto=format&w=1000&fit=clip"><img alt="Older adult customer standing at a pharmacy checkout stand, with pharmacist explaining something." src="https://images.theconversation.com/files/545363/original/file-20230829-17-5vd6tm.jpg?ixlib=rb-1.1.0&rect=34%2C17%2C5657%2C3763&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/545363/original/file-20230829-17-5vd6tm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/545363/original/file-20230829-17-5vd6tm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/545363/original/file-20230829-17-5vd6tm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/545363/original/file-20230829-17-5vd6tm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/545363/original/file-20230829-17-5vd6tm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/545363/original/file-20230829-17-5vd6tm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The first 10 drugs selected for negotiated pricing can be picked up at a pharmacy.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/female-owner-holding-prescription-paper-with-senior-royalty-free-image/944238626?adppopup=true">Maskot/Getty Images</a></span>
</figcaption>
</figure>
<h2>Strong resistance</h2>
<p>It’s too soon to say how big the impact of the drug pricing provisions will be and whether this policy will be sustained. </p>
<p>Drugmakers have opposed any <a href="https://doi.org/10.1111%2Fj.0887-378X.2004.00311.x">governmental regulation of drug prices for decades</a>. They are fighting the <a href="https://www.politico.com/news/2023/08/29/drugmakers-trade-groups-push-back-against-medicare-drug-price-negotiations-00111936">measure in court</a> and running a public relations campaign that warns of reduced investments in life-saving cures because their financial incentives are reduced. </p>
<p>Even if the drug price negotiations survive the industry’s legal challenges, it’s possible that future Republican administrations won’t embrace or enforce this policy. This is because potential Republican wins in the 2024 presidential and congressional elections could unravel or severely curtail the new drug negotiation policy. Indeed, Republicans have been working <a href="https://www.politico.com/news/2023/08/29/biden-drug-prices-gop-00113404">feverishly on designing a strategy</a> to use the negotiations against Democrats in the upcoming elections.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/9qI-2sLtp4M?wmode=transparent&start=12" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">If successful, the price negotiations could substantially lower the cost of some of the most in-demand drugs.</span></figcaption>
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<h2>Weighing the prospects</h2>
<p>In my view, the government’s efforts to cut prices for prescription drugs that Part D enrollees obtain are a step in the right direction. For now, the <a href="https://doi.org/10.18553/jmcp.2023.29.8.868">effect will likely be small</a> because patients already receive discounts on the listed drugs, bringing the net savings down substantially. However, the potential for real savings for Americans ages 65 and older will undoubtedly grow as more drugs become subject to negotiation. </p>
<p>At the same time, drug manufacturers have indicated that they are willing to take their legal battles against the Medicare drug pricing reform <a href="https://www.nytimes.com/2023/07/23/us/politics/medicare-drug-price-negotiations-lawsuits.html">all the way to the Supreme Court</a>. If that happens, there’s a <a href="https://www.medpagetoday.com/opinion/the-health-docket/105818">good chance they will prevail</a> because the arguments made in their lawsuits are likely to appeal to the Supreme Court’s conservative majority, which <a href="https://www.medpagetoday.com/opinion/the-health-docket/105818">has been favorable</a> to many of the arguments made by drugmakers in their lawsuits. </p>
<p>Moreover, drugmakers could also simply pull their drugs from Medicare and Medicaid to force the government’s hand. The Centers for Medicare & Medicaid Services seems to have deliberately chosen drugs that <a href="https://www.statnews.com/2023/08/29/10-drugs-medicare-price-negotiation">make up a high percentage of manufacturers’ drug sales</a> to counter this possibility. The industry has a <a href="https://www.amazon.com/American-Sickness-Healthcare-Became-Business/dp/1594206759">history of skillfully exploiting loopholes</a> and <a href="https://theconversation.com/prescription-drug-costs-would-have-been-a-major-campaign-issue-so-what-will-happen-now-that-coronavirus-is-center-stage-132493">possesses a vast lobbying apparatus</a>. </p>
<p>It’s also too soon to know if this is going to be a win for American patients overall. It’s possible that Americans who aren’t covered by Medicare <a href="https://rollcall.com/2022/08/10/senates-medicare-drug-pricing-may-ripple-into-private-market">may actually see prices go up</a>. That’s because if drugmakers do make less money on drugs for people enrolled in Part D, they might make up for those lost profits by charging more for drugs that other people depend on.</p>
<p>And lastly, it’s possible that there will be <a href="https://www.nytimes.com/2023/07/23/us/politics/medicare-drug-price-negotiations-lawsuits.html">fewer new prescription drugs</a> – as an indirect result of this policy that’s supposed to improve access to health care – because it <a href="https://www.kff.org/medicare/issue-brief/explaining-the-prescription-drug-provisions-in-the-inflation-reduction-act">may reduce drugmakers incentives</a>. While the number of cases is likely small, it would potentially take a toll on patients who might have seen a cure to their disease – or some relief from their symptoms.</p><img src="https://counter.theconversation.com/content/212503/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The drug pricing reform may drastically lower prices for some of the most critical life-saving drugs in the long run. But numerous obstacles stand in the way.Simon F. Haeder, Associate Professor of Public Health, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2110462023-08-30T04:19:59Z2023-08-30T04:19:59ZToo many young people who’ve been in detention die prematurely. They deserve better<figure><img src="https://images.theconversation.com/files/544694/original/file-20230825-25-a34sg8.jpg?ixlib=rb-1.1.0&rect=1%2C0%2C997%2C666&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hand-jail-147711227">Shutterstock</a></span></figcaption></figure><p>Young people in contact with the criminal justice system – be it under community-based orders or in youth detention – are among the <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(19)30217-8/fulltext">most marginalised</a> in our society. And the health and health-care disadvantage faced by these young people may be evident for years.</p>
<p><a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(23)00144-5/fulltext">Our research</a> found high levels of largely-preventable diseases and avoidable premature deaths for these young people in Australia. This indicates inadequate health care both in youth detention and in the community.</p>
<p>It’s time we provided health care for people in youth detention that’s culturally safe and equivalent to what’s available in the community. That includes access to Australia’s so-called universal health-care scheme, Medicare. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/locking-up-kids-damages-their-mental-health-and-sets-them-up-for-more-disadvantage-is-this-what-we-want-117674">Locking up kids damages their mental health and sets them up for more disadvantage. Is this what we want?</a>
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<hr>
<h2>Children as young as 10</h2>
<p>Australian courts can sentence children as young as ten who are convicted of a criminal offence to a community-based order, or to youth detention. </p>
<p>During the 2021-22 financial year, <a href="https://www.aihw.gov.au/getmedia/3fe01ba6-3917-41fc-a908-39290f9f4b55/aihw-juv-140.pdf.aspx?inline=true">4,350 young people</a> aged ten to 18 were detained at some point, typically for eight days or less.</p>
<p>Almost 50% of young people under youth justice supervision <a href="https://www.aihw.gov.au/getmedia/3fe01ba6-3917-41fc-a908-39290f9f4b55/aihw-juv-140.pdf.aspx?inline=true">are Indigenous</a>, and they are 24 times more likely than non-Indigenous young people to go into youth detention.</p>
<p>Young people in detention commonly have <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(19)30217-8/fulltext">very poor health</a>. This includes high rates of one or more physical and mental health problems, cognitive and neurodevelopmental disabilities, and substance dependence. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-social-determinants-of-justice-8-factors-that-increase-your-risk-of-imprisonment-203661">The social determinants of justice: 8 factors that increase your risk of imprisonment</a>
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</em>
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<h2>What we found</h2>
<p>In the nearly 25 years of data covered in our study, <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(23)00144-5/fulltext">we found</a> young people with a history of contact with the youth justice system died at a rate more than four times higher than those of the same age and sex in the general Australian population.</p>
<p>We found those most at risk of dying prematurely were Indigenous children, males, and those whose first contact with the youth justice system was before they were 14 years old.</p>
<p>Until now, there’s been a remarkable lack of evidence on the burden of noncommunicable diseases, such as cancers and cardiovascular diseases, among young people during and after contact with the youth justice system. However, we found that compared with their peers, these young people have nearly double the rate of dying from such diseases.</p>
<p>For young Indigenous males, cardiovascular and digestive diseases, including chronic liver diseases, were particularly prominent (and largely preventable) causes of death.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/first-nations-people-in-the-nt-receive-just-16-of-the-medicare-funding-of-an-average-australian-183210">First Nations people in the NT receive just 16% of the Medicare funding of an average Australian</a>
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</em>
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<h2>What we need</h2>
<p>Our findings highlight the need for young people involved with the justice system to access high-quality and holistic health care that’s age- and culturally appropriate. This is essential to identify and manage their complex health conditions, both during periods of supervision and – critically – after return to the community. </p>
<p>Aboriginal Community Controlled Health Organisations are <a href="https://link.springer.com/article/10.1186/s12889-020-09943-4">well placed</a> to provide this and to support continuity of care as these children transition in and out of detention.</p>
<p>But the Northern Territory is the only jurisdiction where they are funded to provide health care in youth detention.</p>
<p>Aboriginal Community Controlled Health Organisations are unable to access Commonwealth funding to support health care in detention elsewhere.</p>
<p>Discriminatory exclusion from access to Medicare, which typically prevents access to Aboriginal Community Controlled Health Organisations in detention, is an example of the “<a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00243-9/fulltext">inverse care law</a>”. This is when those most in need of high-quality health care are least likely to receive it.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/victorias-prison-health-care-system-should-match-community-health-care-180558">Victoria’s prison health care system should match community health care</a>
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<hr>
<h2>Progress has been slow so far</h2>
<p>Health-care reform in youth justice is clearly and urgently required, but progress has been slow. One reason is the lack of independent oversight of these systems. </p>
<p>Despite <a href="https://www.ombudsman.gov.au/industry-and-agency-oversight/monitoring-places-of-detention-opcat">ratifying</a> the UN Optional Protocol to the Convention against Torture in 2017, Australia has <a href="https://theconversation.com/australias-twice-extended-deadline-for-torture-prevention-is-today-but-weve-missed-it-again-197793">yet to establish</a> the mechanisms required under this protocol to permit independent scrutiny of places of detention. </p>
<p>As a priority, we need to meet our international obligations – through both permitting unfettered access to all youth detention centres and investing appropriately in <a href="https://www.ombudsman.gov.au/industry-and-agency-oversight/monitoring-places-of-detention-opcat">independent scrutiny</a> – in every state and territory.</p>
<p>Australia is also lagging behind in routine monitoring of health and health care in youth detention. More than five years ago, the Australian Institute of Health and Welfare <a href="https://www.aihw.gov.au/reports/youth-justice/health-justice-involved-young-people-2016-17/summary">recommended</a> producing regular reports on health care in youth justice settings. But there is still no Commonwealth or state/territory funding or mechanism for this critical monitoring.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australias-twice-extended-deadline-for-torture-prevention-is-today-but-weve-missed-it-again-197793">Australia's twice extended deadline for torture prevention is today, but we've missed it again</a>
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</em>
</p>
<hr>
<h2>Why we need to lift our game</h2>
<p>Improving the health of this marginalised group is important to improving health equity, closing the gap, and preventing the tragic loss of young lives. </p>
<p>Australia can no longer ignore that some of our most disadvantaged children are dying at a much faster rate than expected, and from causes that are largely preventable. Doing so would amplify cycles of racism and social exclusion. </p>
<p>Under the <a href="https://www.unicef.org.au/united-nations-convention-on-the-rights-of-the-child">UN Convention on the Rights of the Child</a> all children, including those in contact with the youth justice system, have the right to the highest attainable standard of health. We owe it to them to make this a reality.</p><img src="https://counter.theconversation.com/content/211046/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lucas Calais Ferreira receives funding from Suicide Prevention Australia.</span></em></p><p class="fine-print"><em><span>Stuart Kinner receives funding from the National Health and Medical Research Council. </span></em></p><p class="fine-print"><em><span>Professor Susan Sawyer is a member of the Youth Justice Act Independent Expert Group for the Victorian Government, Department of Justice and Community Safety.</span></em></p><p class="fine-print"><em><span>Alex Brown 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>Children as young as ten don’t have access to Medicare if detained. And they’re dying of largely preventable diseases.Lucas Calais Ferreira, Postdoctoral Research Fellow, The University of MelbourneAlex Brown, Professor of Indigenous Genomics, Australian National UniversityStuart Kinner, Professor of Health Equity, Curtin UniversitySusan M Sawyer, Professor of Adolescent Health The University of Melbourne; Director, Royal Children's Hospital Centre for Adolescent Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2114172023-08-28T20:03:47Z2023-08-28T20:03:47ZTranscranial magnetic stimulation can treat depression. Developing research suggests it could also help autism, ADHD and OCD<p>Since the start of the COVID pandemic, there has been more attention given to problems of mental ill-health including depression <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01328-9/fulltext">than ever before</a>. A new therapeutic option, especially for depression, transcranial magnetic stimulation, is slowly helping to address some of these considerable unmet needs in our community. </p>
<p>Research is also exploring the use of transcranial magnetic stimulation in many other conditions, including obsessive compulsive disorder, autism, attention deficit hyperactivity disorder, chronic pain and perhaps to slow the progression of dementia symptoms.</p>
<p>What do we know so far about this emerging form of treatment? And is it living up to its promise for people with depression?</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/treating-mental-illness-with-electricity-marries-old-ideas-with-modern-tech-and-understanding-of-the-brain-podcast-195071">Treating mental illness with electricity marries old ideas with modern tech and understanding of the brain – podcast</a>
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</em>
</p>
<hr>
<h2>How does it work and who’s getting it now?</h2>
<p><a href="https://theconversation.com/what-is-repetitive-transcranial-magnetic-stimulation-and-how-does-it-actually-work-160771">Transcranial magnetic stimulation</a> involves the application of a series of magnetic pulses through a coil placed on the scalp. While the patient sits in a chair awake and relaxed, the magnetic field activates nerve cells in the brain, gradually changing the activity of brain circuits disrupted in depression. This is thought to help restore the normal interaction between brain regions.</p>
<p>Side effects are <a href="https://www.mayoclinic.org/tests-procedures/transcranial-magnetic-stimulation/about/pac-20384625#:%7E:text=Serious%20side%20effects%20are%20rare,t%20well%2Dprotected%20during%20treatment.">usually mild</a> and temporary. They may include scalp discomfort, headache, tingling or facial twitching, and feeling lightheaded for a short time after a treatment session.</p>
<p>There is consistent evidence for the <a href="https://journals.sagepub.com/doi/10.1177/00048674211043047">effectiveness</a> of transcranial magnetic stimulation treatment for acute episodes of depression. Its use is supported by many clinical trials as well as real-world studies showing benefits in more than <a href="https://pubmed.ncbi.nlm.nih.gov/32799106/">50% of patients receiving treatment</a>. It attracted Medicare funding several years ago and is now being progressively rolled out around Australia. </p>
<p>But there are several remaining problems with the use of transcranial magnetic stimulation treatment. First, it involves a patient coming into the clinic daily, Monday to Friday, for four to six weeks. This is inefficient and costly. </p>
<p>Both these problems may ultimately be solved through the development of what are referred to as “accelerated” protocols – treatments that give higher doses on fewer days. A patient may have four or five days of high-dose treatment in one week rather than having all of the treatment dose spread out over a month or more. </p>
<p><a href="https://www.nature.com/articles/s41386-023-01599-z">Studies</a> both locally and overseas have started to show more efficient delivery and <a href="https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2019.19070720">very rapid clinical benefits</a> with these new treatment regimes.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&rect=65%2C5%2C3928%2C1988&q=45&auto=format&w=1000&fit=clip"><img alt="man sits in lab setting with equipment on" src="https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&rect=65%2C5%2C3928%2C1988&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=300&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=300&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=300&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=377&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=377&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=377&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The lasting effects and need for maintenance doses of transcranial magnetic stimulation need further study.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/patient-transcranial-magnetic-stimulation-tms-experiment-426901186">Shutterstock</a></span>
</figcaption>
</figure>
<h2>What about for other conditions?</h2>
<p>Alongside the clinical rollout of transcranial magnetic stimulation for depression, research is increasingly demonstrating its potential value in other conditions. </p>
<p>A series of studies have demonstrated that a somewhat different type of transcranial magnetic stimulation, which is able to stimulate deeper regions of the brain but which still comes from a scalp based coil, can be effective in the treatment of symptoms in some patients with <a href="https://iocdf.org/about-ocd/ocd-treatment/tms/">obsessive compulsive disorder</a> (OCD). This is a critical development as many patients with OCD fail to improve with medication and psychological treatments and there are few new therapies in development for the condition. </p>
<p>Transcranial magnetic stimulation for OCD has been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8864803/#:%7E:text=Aside%20from%20MDD%2C%20the%20next,adults%20in%202017%20(DEN170078).">approved</a> for clinical use in the United States and is available in a limited number of clinical services in Australia.</p>
<p>The treatment is showing promise for <a href="https://www.mdpi.com/2077-0383/11/3/624">addiction disorders</a>, including the development of an approach using transcranial magnetic stimulation to <a href="https://www.sciencedirect.com/science/article/pii/S0165178123002901">help patients stop smoking</a>. The initial trial of this approach showed at least a doubling of the percentage of patients who did not smoke over the first six weeks. </p>
<p>Transcranial magnetic stimulation may also help people manage chronic pain. Multiple approaches that use the technology show promise and <a href="https://www.sciencedirect.com/science/article/abs/pii/S0987705319301789?via%3Dihub">guidelines are emerging</a>, but a consistent clinical pathway has not yet been well defined.</p>
<p>A group of researchers across the country, led by <a href="https://tmsautism.com/">Professor Peter Enticott in Melbourne</a>, are conducting world-leading research trying to develop ways of using transcranial magnetic stimulation to help adolescent and adult patients with autism, especially to improve capacity for social understanding and interaction.</p>
<p>As clinical need escalates, early research is also exploring whether transcranial magnetic stimulation might alleviate symptoms of <a href="https://mecp.springeropen.com/articles/10.1186/s43045-022-00210-3">attention deficit hyperactivity disorder (ADHD)</a>. </p>
<p>Research has already demonstrated transcranial magnetic stimulation may improve, at least temporarily, thinking abilities in a range of disorders including <a href="https://www.frontiersin.org/articles/10.3389/fnagi.2022.984708/full">Alzheimer’s disease</a>. This is now being applied to see if it can improve attention for patients with ADHD. For now, this research remains in its infancy.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1689015899963961344"}"></div></p>
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Read more:
<a href="https://theconversation.com/people-with-obsessive-compulsive-disorder-have-an-imbalance-of-brain-chemicals-our-discovery-could-mean-a-treatment-breakthrough-208549">People with obsessive-compulsive disorder have an imbalance of brain chemicals – our discovery could mean a treatment breakthrough</a>
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<h2>Do the effects last?</h2>
<p>So far, the quality of the <a href="https://doi.org/10.1016/j.jad.2021.09.040">evidence</a> on the persistence of effects and the need for maintenance treatment with the use of transcranial magnetic stimulation in depression is patchy. Research is looking at whether ongoing transcranial magnetic stimulation less often (for example one treatment every two weeks) may prevent the recurrence of depression in patients who have responded well. <a href="https://pubmed.ncbi.nlm.nih.gov/31399997/">Preliminary studies</a> suggest maintenance treatment is effective, but there there have been insufficient high-quality studies to convince Medicare to provide a subsidy for it. </p>
<p>Medicare funding also does not fund the provision of transcranial magnetic stimulation for patients who experience the return of their depression on more than one occasion.</p>
<p>This is highly unusual. Patients with depression can have multiple courses of antidepressant medication, psychotherapy or electroconvulsive therapy based on similar levels of evidence. This is also true of most other medical therapies. </p>
<p>In clinical practice, and from the <a href="https://doi.org/10.1016/j.jad.2020.06.067">limited evidence available</a>, it seems clear that if a patient has responded on one occasion to transcranial magnetic stimulation, they are likely to again. Until this is resolved, patients are in an unenviable situation. They know there is an effective treatment that has worked for them already, but they can only access it at considerable expense or via lengthy private hospital admission.</p><img src="https://counter.theconversation.com/content/211417/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Fitzgerald is a founder of TMS Clinics Australia / Monarch Mental Health Group which provides rTMS therapy through 21 clinics in three states of Australia. He has received grant funding from the NHMRC to support clinical trials into the use of rTMS. He was the author of several applications to the Medicare Services Advisory Committee seeking an item number for rTMS therapy for depression which led to the current approval.</span></em></p>What do we know so far about this promising form of treatment and how it might help people with a range of neurological conditions? And is it living up to its promise for people with depression?Paul B. Fitzgerald, Professor of Psychiatry, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2113982023-08-22T12:25:59Z2023-08-22T12:25:59ZMost US nursing homes are understaffed, potentially compromising health care for more than a million elderly residents<figure><img src="https://images.theconversation.com/files/542411/original/file-20230811-21-ml692x.jpg?ixlib=rb-1.1.0&rect=0%2C23%2C7959%2C5266&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nursing homes in poorer neighborhoods tend to have more critical staffing issues.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/young-male-care-worker-helping-woman-off-bed-with-royalty-free-image/1433524154?phrase=nursing+home&adppopup=true">10'000 Hours/Digital Vision via Getty Images</a></span></figcaption></figure><p><em>More than 80% of U.S. nursing homes <a href="https://thehill.com/changing-america/well-being/longevity/3809450-more-than-8-in-10-nursing-homes-face-staffing-shortages-survey/#:%7E">reported staffing shortages</a> in early 2023. SciLine interviewed <a href="https://nursing.nyu.edu/directory/faculty/jasmine-travers">Dr. Jasmine Travers</a>, a gerontological nurse practitioner and assistant professor of nursing at New York University Rory Meyers College of Nursing, and asked her how the shortage affects health care for nursing home residents, if nursing homes in poorer neighborhoods have been hit harder by the shortages, and what can be done to fix the problem.</em></p>
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<figcaption><span class="caption">Dr. Jasmine Travers discussed the impact when nursing homes are short-staffed.</span></figcaption>
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<p><em>Below are some highlights from the discussion. Answers have been edited for brevity and clarity.</em></p>
<p><strong>Who lives in nursing homes in the United States?</strong></p>
<p><strong>Jasmine Travers:</strong> There are 15,000 nursing homes with approximately <a href="https://oig.hhs.gov/reports-and-publications/featured-topics/nursing-homes/">1.2 million residents</a>. That population can range in age, although most commonly it’s those 65 years of age or older.</p>
<p><strong>What is the current state of nursing home staffing?</strong></p>
<p><strong>Jasmine Travers:</strong> In 2001, the Centers for Medicare & Medicaid Services proposed minimum staffing standards. They indicated that total nursing hours should be <a href="https://doi.org/10.1177/1178632920934785">4.1 hours per resident per day</a>. And that’s including the registered nurse, the licensed practical nurse and the certified nursing assistants. Only 25% of nursing homes were found <a href="https://doi.org/10.1111/jgs.17678">to be meeting those total nursing hours</a> in 2019.</p>
<p><strong>How did the COVID-19 pandemic affect nursing home occupancy and staffing?</strong></p>
<p><strong>Jasmine Travers:</strong> Occupancy levels hovered at about 80% prior to the pandemic. During the pandemic, occupancy went down to a low of 67%. By the end of 2022, those levels <a href="https://www.statista.com/statistics/1223881/occupancy-rate-of-certified-nursing-facilities-in-the-united-states/">had gone up to 72%</a>. </p>
<p>Lower occupancy levels can be a significant issue. Higher occupancy brings in more revenue to the nursing homes. With lower occupancy and less revenue coming in, then that’s a decrease in financial support that the nursing home needs to run their day-to-day activities.</p>
<p><strong>How does nursing home staffing affect the quality of care and health outcomes for residents?</strong></p>
<p><strong>Jasmine Travers:</strong> A number of studies show that when staffing is low, <a href="https://doi.org/10.1177/1178632920934785">emergency hospitalization visits</a> increase. Some of these visits could have been addressed by care provided in the nursing home setting. We also see increased instances of <a href="https://doi.org/10.1016/j.jamda.2004.12.003">pressure ulcers</a>, <a href="https://doi.org/10.1093/geronb/55.5.S278">urinary tract infections</a>, <a href="http://dx.doi.org/10.14283/jnhrs.2020.24">falls</a> and <a href="https://doi.org/10.1080/08959420.2011.532011">deficiency citations</a> – issued when a nursing home does not <a href="https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/SCLetter08-10.pdf">meet a certification minimum standard</a>. </p>
<p>When nursing homes are understaffed, that means there might not be a sufficient number of certified nursing assistants to, for example, answer call bells. That might translate to residents sitting in their beds needing help for longer periods of time. </p>
<p>In those instances, if a person doesn’t have someone to get them out of bed, sometimes they might try to get up themselves. And when they do that, they could be at risk of falling. Or if they stay in bed and they’re soiled, they’re at increased risk for urinary tract infections or pressure ulcers. </p>
<p><strong>What can be done to alleviate nursing home staffing challenges?</strong></p>
<p><strong>Jasmine Travers:</strong> Areas that are socioeconomically deprived or that lack good transportation, housing and schools are less <a href="https://doi.org/10.1111/jgs.17990">desirable places to work</a>. </p>
<p>Just recently, the Centers for Medicare & Medicaid Services released an announcement that they are going to allow for those in pediatric specialties to receive loan reimbursements and loan forgiveness <a href="https://www.hhs.gov/about/news/2023/06/09/hhs-announces-new-15-million-loan-repayment-program-strengthen-pediatric-health-care-workforce.html">for working in underserved areas</a>. A similar program for those working in nursing homes would likely increase staffing. </p>
<p>I’d also like to see improved wages and benefits and more investment in retention efforts to keep the people who are already working in nursing homes working there.</p>
<p>One of the biggest issues when it comes to staffing is turnover. People will stay when the work environment is changed. And when people stay longer, they know their residents more. That consistency translates to better quality of care.</p>
<p>Watch the <em><a href="https://www.sciline.org/health-medicine/nursing-home-staffing/">full interview</a></em> to hear more.</p>
<p><em><a href="https://www.sciline.org/">SciLine</a> is a free service based at the nonprofit American Association for the Advancement of Science that helps journalists include scientific evidence and experts in their news stories.</em></p><img src="https://counter.theconversation.com/content/211398/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jasmine Travers receives funding from Robert Wood Foundation and the National Institutes of Health. </span></em></p>Reduced staffing means nursing home residents make more unnecessary trips to the hospital.Jasmine Travers, Assistant Professor of Nursing, New York UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2109812023-08-13T20:04:05Z2023-08-13T20:04:05ZPrivate health insurance is set for a shake-up. But asking people to pay more for policies they don’t want isn’t the answer<figure><img src="https://images.theconversation.com/files/541841/original/file-20230809-17-cw90xj.jpg?ixlib=rb-1.1.0&rect=2%2C4%2C995%2C661&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/businesswoman-work-laptop-phone-connect-internet-497999221">Shutterstock</a></span></figcaption></figure><p>Private health insurance is <a href="https://consultations.health.gov.au/medical-benefits-division/consultation-on-phi-studies/">under review</a>, with proposals to overhaul everything from rebates to tax penalty rules.</p>
<p>One <a href="https://consultations.health.gov.au/medical-benefits-division/consultation-on-phi-studies/supporting_documents/Finity%20Consulting%20MLS%20and%20PHI%20Rebate%20Final%20Report.pdf">proposal</a> is for higher-income earners who don’t have private health insurance to pay a larger <a href="https://www.ato.gov.au/Individuals/Medicare-and-private-health-insurance/Medicare-levy-surcharge/">Medicare Levy Surcharge</a> – an increase from 1.25% or 1.5%, to 2%. And if they want to avoid that surcharge, they’d need to take out higher-level hospital cover than currently required.</p>
<p>Encouraging more people to take up private health insurance like this might seem a good way to take pressure off the public hospital system. </p>
<p>But <a href="https://melbourneinstitute.unimelb.edu.au/publications/working-papers/search/result?paper=4682822">our research</a> shows these proposals may not achieve this. These may also be especially punitive for people with little to gain from buying private health insurance, such as younger people and those living in regional areas who do not have access to private hospitals.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/do-you-really-need-private-health-insurance-heres-what-you-need-to-know-before-deciding-93661">Do you really need private health insurance? Here's what you need to know before deciding</a>
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<h2>What is the Medicare Levy Surcharge?</h2>
<p>The Medicare Levy Surcharge was <a href="https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/FlagPost/2013/May/A_short_history_of_increases_to_the_Medicare_levy#:%7E:text=From%20July%201997%2C%20a%20surcharge,ancillary%20insurance%20cover%20was%20introduced">introduced in 1997</a> to encourage high-income earners to buy health insurance. People earning above the relevant thresholds need to buy “complying” health insurance, or pay the levy.</p>
<p>This surcharge is in addition to the <a href="https://www.ato.gov.au/Individuals/Medicare-and-private-health-insurance/Medicare-levy/">Medicare levy</a>, which applies to most taxpayers.</p>
<p>The surcharge varies depending on your income bracket, and the rate is <a href="https://www.ato.gov.au/Individuals/Medicare-and-private-health-insurance/Medicare-levy-surcharge/Medicare-levy-surcharge-income,-thresholds-and-rates/">different</a> for families.</p>
<p>For instance, to avoid paying the surcharge currently, a single person living in Victoria earning A$108,001 can buy basic hospital cover. The lowest annual premium for someone under 65 is <a href="https://www.privatehealth.gov.au/dynamic/Search/">about $1,100</a>, after rebates. That varies slightly between states and territories.</p>
<p>Not buying private health insurance and paying the Medicare Levy Surcharge instead would cost even more, at $1,350 (1.25% of $108,001).</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/if-youve-got-private-health-insurance-the-choice-to-use-it-in-a-public-hospital-is-your-own-113367">If you've got private health insurance, the choice to use it in a public hospital is your own</a>
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</em>
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<h2>What is being proposed?</h2>
<p>The <a href="https://consultations.health.gov.au/medical-benefits-division/consultation-on-phi-studies/">report</a>, by Finity Consulting and commissioned by the federal health department, reviews a range of health insurance incentives. </p>
<p>It recommends increasing the Medicare Levy Surcharge to 2% for those with an income above $108,001 for singles, and $216,001 for families.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/541892/original/file-20230809-27-9rg8wm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Tax forms from Australian Taxation Office" src="https://images.theconversation.com/files/541892/original/file-20230809-27-9rg8wm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/541892/original/file-20230809-27-9rg8wm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=381&fit=crop&dpr=1 600w, https://images.theconversation.com/files/541892/original/file-20230809-27-9rg8wm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=381&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/541892/original/file-20230809-27-9rg8wm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=381&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/541892/original/file-20230809-27-9rg8wm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=479&fit=crop&dpr=1 754w, https://images.theconversation.com/files/541892/original/file-20230809-27-9rg8wm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=479&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/541892/original/file-20230809-27-9rg8wm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=479&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">People on higher incomes without private health insurance need to pay the Medicare Levy Surcharge via the taxation system.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/australian-individual-tax-return-form-176951723">Shutterstock</a></span>
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<p>The definition of a “complying” private health insurance policy would also change. </p>
<p>Rather than having basic hospital cover as is required now, someone would need to buy <a href="https://www.health.gov.au/resources/publications/private-health-insurance-reforms-gold-silver-bronze-basic-product-tiers-campaign-fact-sheet?language=en">silver or gold</a> cover to avoid the surcharge.</p>
<p>Under the proposed changes, people who pay the 2% surcharge would also no longer receive any rebate, which currently reduces premiums by <a href="https://www.ato.gov.au/Individuals/Medicare-and-private-health-insurance/Private-health-insurance-rebate/Income-thresholds-and-rates-for-the-private-health-insurance-rebate/#Rebaterates1">about 8%</a> for people earning $108,001-$144,000. </p>
<p>So, for a single person under 65, earning $108,001 and living in Victoria, the <a href="https://www.privatehealth.gov.au/dynamic/Search/">annual cost of buying</a> complying hospital cover would be at least $1,904 (without the rebate). Again, that varies slightly between states and territories.</p>
<p>But the cost of not insuring and paying the Medicare Levy Surcharge instead would go up to $2,160 (2% of $108,001).</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-switch-health-insurers-if-youre-worried-about-cybersecurity-costs-or-claims-194248">How to switch health insurers if you're worried about cybersecurity, costs or claims</a>
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<h2>Is this a good idea?</h2>
<p>However, <a href="https://melbourneinstitute.unimelb.edu.au/publications/working-papers/search/result?paper=4682822">our research</a>, out earlier this year, suggests increasing the Medicare Levy Surcharge will not meaningfully increase take-up of private health insurance. We’ve shown that people do not respond as strongly to the surcharge as theory would predict. </p>
<p>For example, when the surcharge kicks in, we found the probability of insuring only increases modestly from about 70% to 73% for singles, and about 90% to 91% for families.</p>
<p>It is generally cheaper to buy private health insurance than to pay the surcharge. However, we found about 15% of single people with an income of $108,001 or above don’t insure despite it being cheaper than paying the Medicare Levy Surcharge. </p>
<p>We don’t know precisely why. Maybe people are not sure of the financial benefit due to changes in their income, or if they are, cannot be bothered, or do not have time, to explore their options.</p>
<figure class="align-center ">
<img alt="Medicare card" src="https://images.theconversation.com/files/541891/original/file-20230809-13146-b42ojv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/541891/original/file-20230809-13146-b42ojv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/541891/original/file-20230809-13146-b42ojv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/541891/original/file-20230809-13146-b42ojv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/541891/original/file-20230809-13146-b42ojv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/541891/original/file-20230809-13146-b42ojv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/541891/original/file-20230809-13146-b42ojv.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">Some people may choose to pay more tax for public services including Medicare.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/australian-medicare-card-over-textured-background-500169142">Shutterstock</a></span>
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<p>Maybe, as <a href="https://www.reddit.com/r/AusFinance/comments/x2909w/does_anyone_else_willingly_pay_the_medicare/">anecdotal reports suggest</a>, rather than buying private health insurance, some people would rather support the public system by paying the Medicare Levy Surcharge. </p>
<p>The point is, people who are not buying private health insurance appear to be highly resistant to financial incentives. So stronger penalties might have little effect.</p>
<p>Instead, we propose the Medicare Levy Surcharge be better targeted to true high-income earners. We can do that by increasing income thresholds for the surcharge to kick in, which are then indexed annually to reflect changes in earnings.</p>
<h2>How about needing more expensive cover?</h2>
<p>Requiring people to choose silver level cover or above would address criticisms about people buying “<a href="https://theconversation.com/getting-rid-of-junk-health-insurance-policies-is-just-tinkering-at-the-margins-of-a-much-bigger-issue-82749">junk</a>” private health insurance they never intend to use. </p>
<p>However, people may be buying this type of product because private health insurance has little value to them. Requiring them to spend even more on a product they don’t want is a roundabout way of taking pressure off the public system. </p>
<p>So we propose keeping the current level of hospital cover required to avoid the surcharge, rather than increasing it.</p>
<h2>Who loses?</h2>
<p>Taken together, the cost of these proposed changes would disproportionately fall on people with little to gain from private health insurance. These include younger people, those living in regional areas who do not have access to private hospitals, or those who prefer to support the public system directly.</p>
<p>These groups are the least likely to use private insurance so have the least to gain from upgrading their cover.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/getting-rid-of-junk-health-insurance-policies-is-just-tinkering-at-the-margins-of-a-much-bigger-issue-82749">Getting rid of junk health insurance policies is just tinkering at the margins of a much bigger issue</a>
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<h2>Where to next?</h2>
<p>The report also recommends keeping <a href="https://www.ato.gov.au/Individuals/Medicare-and-private-health-insurance/Private-health-insurance-rebate/">health insurance rebates</a> (a government contribution to your premiums), the <a href="https://www.ato.gov.au/Individuals/Medicare-and-private-health-insurance/Private-health-insurance-rebate/Lifetime-health-cover/">Lifetime Health Cover</a> loading (to encourage people to take out hospital cover while younger), as well as the Medicare Levy Surcharge.</p>
<p>We also support keeping these three in the short to medium term.</p>
<p>But we recommend gradually reducing public support for private health insurance.</p>
<p>We believe the ultimate goal of reforming private health insurance is to optimise the overall efficiency of the health-care system (both public and private systems) and improve population health while saving taxpayers’ money. </p>
<p>The goal should not be merely increasing the take-up of private health insurance, which is the focus of the current report.</p>
<p>So, as well as our recommendation to better target the Medicare Levy Surcharge, we need to:</p>
<ul>
<li><p>lower income thresholds for <a href="https://theconversation.com/the-private-health-insurance-rebate-has-cost-taxpayers-100-billion-and-only-benefits-some-should-we-scrap-it-181264">insurance rebates</a>, especially targeting those on genuinely low incomes. This means lower premiums only for the people who can least afford private health care</p></li>
<li><p>remove rebates <a href="https://theconversation.com/private-health-insurance-premiums-should-be-based-on-age-and-health-status-122545">based on age</a> as higher rebates for older people <a href="https://www.tandfonline.com/doi/abs/10.1080/13504851.2017.1299094?journalCode=rael20">do not</a> encourage more to insure. Rebates should be tied to just income, which is a better indicator of financial means.</p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/private-health-insurance-premiums-should-be-based-on-age-and-health-status-122545">Private health insurance premiums should be based on age and health status</a>
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</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/210981/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Yuting Zhang receives funding from the Australian Research Council, Department of Veterans' Affairs, the Victorian Department of Health, and National Health and Medical Research Council. In the past, Professor Zhang has received funding from several US institutes including the US National Institutes of Health, Commonwealth fund, Agency for Healthcare Research and Quality, and Robert Wood Johnson Foundation. She has not received funding from for-profit industry including the private health insurance industry.</span></em></p><p class="fine-print"><em><span>Nathan Kettlewell does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>People on higher incomes without private health insurance don’t seem to be swayed by financial incentives, our research shows.Yuting Zhang, Professor of Health Economics, The University of MelbourneNathan Kettlewell, Chancellor's Postdoctoral Research Fellow, Economics Discipline Group, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2085272023-07-26T12:18:41Z2023-07-26T12:18:41ZWhere the government draws the line for Medicaid coverage leaves out many older Americans who may need help paying for medical and long-term care bills – new research<figure><img src="https://images.theconversation.com/files/539037/original/file-20230724-23-hxz8n7.jpg?ixlib=rb-1.1.0&rect=0%2C738%2C3929%2C2144&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many older people with health insurance coverage through Medicare still can't afford the care they need.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/senior-healthcare-assistance-in-a-home-royalty-free-image/1397246920?phrase=elder+care+drugs&adppopup=true">RichLegg/E+ via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p>
<h2>The big idea</h2>
<p>Medicaid, which provides low-income Americans with health insurance coverage, currently excludes large numbers of adults over 65 with social, health and financial profiles similar to those of people the program does cover. Based on a <a href="https://doi.org/10.1080/08959420.2023.2195784">study we conducted</a>, we determined that if <a href="https://www.medicaid.gov/medicaid/eligibility/seniors-medicare-and-medicaid-enrollees/index.html">strict eligibility rules for Medicaid</a> were changed to help cover such people, from 700,000 to 11.5 million people over 65 would be newly eligible for the program.</p>
<p>We analyzed data from the 2018 <a href="https://hrs.isr.umich.edu/about">Health and Retirement Study</a>, a large national survey of older adults conducted by the Institute for Social Research at the University of Michigan every two years, to determine how using five different financial eligibility criteria would increase the number of older adults who would qualify for Medicaid and what they would look like.</p>
<p>Depending on which rules were changed, we would expect to see one of the following scenarios:</p>
<ul>
<li><p>If the government switched from the <a href="https://healthcare.gov/glossary/federal-poverty-level-fpl/">official poverty measurement Medicaid uses</a> – currently an annual income of US$14,580 for one person – to its more accurate <a href="https://www.census.gov/topics/income-poverty/supplemental-poverty-measure.html">supplemental one</a>, which takes taxes, health care costs and certain other expenses into account, about 700,000 more older Americans would get Medicaid coverage.</p></li>
<li><p>If the <a href="https://www.verywellhealth.com/your-assets-magi-and-medicaid-eligibility-4144975">amount of assets that people can have</a> were in line with other programs, such as the <a href="https://www.medicare.gov/medicare-savings-programs">Medicare Savings Plan</a>, an additional 1.4 million people would qualify. Medicare Savings Programs help pay Medicare costs for older adults with limited income and savings.</p></li>
<li><p>If Medicaid stopped <a href="https://www.agingcare.com/articles/asset-limits-to-qualify-for-medicaid-141681.htm">considering assets</a> altogether, an additional 2 million would qualify. </p></li>
<li><p>If the income eligibility threshold were higher, equal to 138% of the <a href="https://www.healthinsurance.org/glossary/federal-poverty-level/">federal poverty level</a>, it would <a href="https://www.medicaid.gov/medicaid/eligibility/index.html">mirror how the government determines</a> whether adults under 65 can get Medicaid, and 4.7 million more older people could be covered by the program. </p></li>
<li><p>A measure that’s increasingly used to evaluate the vulnerability of older adults is the <a href="https://theconversation.com/turning-gray-and-into-the-red-the-true-cost-of-growing-old-in-america-127162">Elder Index</a>, which takes into account basic expenses like housing, health care and food. People over 65 with incomes that fall <a href="https://www.census.gov/library/visualizations/2021/demo/poverty_measure-how.html">above the official poverty line</a> but below the Elder Index are considered to be financially vulnerable. If the government used the Elder Index as a basis for Medicaid eligibility, 11.5 million additional older adults would qualify for the program.</p></li>
</ul>
<p>Unless the government adopted the Elder Index approach, most of the additional enrollees in these scenarios would have poor health and few financial assets.</p>
<h2>Why it matters</h2>
<p>The extra Medicaid enrollment would be in addition to the <a href="https://www.medicaid.gov/medicaid/eligibility/seniors-medicare-and-medicaid-enrollees/index.html">7.2 million older people</a> already in the program.</p>
<p>All the people who would potentially qualify under these different eligibility standards are unable to shoulder even modest long-term care costs without <a href="https://www.aarp.org/aarp-foundation/our-work/income/public-benefits-guide-senior-assistance/">public assistance</a> aside from their <a href="https://www.ssa.gov/news/press/factsheets/basicfact-alt.pdf">Social Security benefits</a> – one of the largest risks facing the over <a href="https://aspe.hhs.gov/reports/what-lifetime-risk-needing-receiving-long-term-services-supports-0">70% of older adults</a> who will have such needs. This risk persists in part because Medicare does not cover such needs. </p>
<p>Low-income adults who are excluded from Medicaid under existing criteria also face high health care costs that contribute to their financial insecurity. Researchers found that <a href="https://doi.org/10.1001/jamanetworkopen.2023.14211">1 in 5 Americans over 65 skipped, delayed or used less</a> medical care or drugs because of financial constraints. </p>
<p>Increasing the number of low-income older people with both Medicaid and Medicare coverage would reduce their out-of-pocket health spending. That would make it <a href="https://doi.org/10.1016/j.jfineco.2019.10.008">easier for them to hang on to their modest savings</a> and also enable them to expand their own caregiving options should they have high medical or <a href="https://www.aplaceformom.com/caregiver-resources/articles/average-cost-long-term-care">long-term care expenses</a> as they age.</p>
<h2>What still isn’t known</h2>
<p>Increasing the number of older people with Medicaid coverage would require more government funding, although the degree of extra spending would depend on which rules the government would change.</p>
<p>Based on the average cost per Medicaid user, our rough estimates suggest that the cost of expanding Medicaid coverage for older people in the first four of the five scenarios we considered would range between about $8 billion and about $51 billion per year. We could not provide an estimate for the Elder Index scenario because the profile of individuals brought into the program would be substantially different from the current Medicaid users, so the per-person costs would be harder to predict.</p>
<p>Accurately estimating these costs and the potential benefits for families and communities that would come from these changes would require additional research.</p><img src="https://counter.theconversation.com/content/208527/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marc Cohen receives funding from the National Council on Aging (NCOA).</span></em></p><p class="fine-print"><em><span>Jane Tavares receives funding from the National Council on Aging</span></em></p>Increasing the number of older people with both Medicaid and Medicare would mean fewer of them would be forced to skimp on the care and treatment they need.Marc Cohen, Clinical Professor of Gerontology and Co-Director LeadingAge LTSS Center, UMass BostonJane Tavares, Senior Research Fellow and Lecturer of Gerontology, LeadingAge LTSS Center @UMass Boston, UMass BostonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2061832023-07-17T20:02:39Z2023-07-17T20:02:39ZShould you register with a GP? What is MyMedicare and how might it change the care you get?<figure><img src="https://images.theconversation.com/files/533371/original/file-20230622-8583-mxjvpt.jpg?ixlib=rb-1.1.0&rect=7%2C22%2C4977%2C3295&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/british-gp-examining-young-child-mother-98508353">Shutterstock</a></span></figcaption></figure><p><a href="https://www.health.gov.au/our-work/mymedicare">MyMedicare</a> is a new voluntary scheme that allows patients to register with their usual GP, in an attempt to improve continuity of care and health outcomes.</p>
<p>From October 1, the scheme will give registered patients access to longer telehealth consultations. Then, from next year, GP clinics with patients who are frequently admitted to hospital or are aged care residents will be able to access additional “blended” funding, which sits outside Medicare’s usual fee-for-service. </p>
<p>MyMedicare was announced in the May budget, with A$19.7 million of funding over four years, alongside a range of <a href="https://www.health.gov.au/sites/default/files/2023-05/building-a-stronger-medicare-budget-2023-24_0.pdf">other health reforms</a>, including funding for practice nurses to improve team-based care, as well as new incentives to increase bulk billing rates. </p>
<p>We’re still waiting on a lot of detail about how the scheme will function. But here’s what we know so far – and what it might mean for patients and GPs. </p>
<h2>What do we know about MyMedicare?</h2>
<p>The scheme is voluntary for GPs and patients. In addition to patients opting in, GPs will also need to sign up, and have been able to do so since the start of July. There will be a gradual roll out and it will take three years to cover all of Australia. </p>
<p>Though details are yet to be confirmed, from mid-2024 individual GPs will receive “<a href="https://www.acponline.org/about-acp/about-internal-medicine/career-paths/residency-career-counseling/resident-career-counseling-guidance-and-tips/understanding-capitation">capitation</a>” payments for patients who have more than ten hospital admissions per year. These patients are likely to have complex needs and multiple conditions and, for various reasons, may not be able to access a GP as much as they should. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-budget-has-big-changes-reviving-our-worn-out-medicare-fee-for-service-system-and-boosting-bulk-billing-204527">Health budget has big changes – reviving our worn-out Medicare fee-for-service system and boosting bulk billing</a>
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</p>
<hr>
<p>Though not yet confirmed, GPs are likely to <a href="https://www.ausdoc.com.au/news/the-mymedicare-enrolment-scheme-is-open-for-gp-practices-should-you-sign-up-now/">receive</a> $2,000 per patient per year, plus a $500 bonus for keeping patients out of hospital. The funding provides incentives for the GP to coordinate their care and provide the patient with access to nursing and allied health if required. It’s hoped this will stop patients going to hospital as often.</p>
<p>There will also be similar payments for providing regular visits to patients in residential aged care facilities. </p>
<h2>Will MyMedicare make a difference to patients?</h2>
<p>Let’s consider four key areas patients are concerned about: </p>
<p><strong>1) Continuity of care</strong></p>
<p>Research shows greater <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2753.2009.01235.x">continuity of care</a> – developing a relationship with and seeing the same provider or team for your care – improves patient outcomes and reduces costs to the health system. People who use MyMedicare to get a regular GP may see some of these benefits.</p>
<p>But many patients already see the same GP or visit the same practice, especially those with chronic conditions. So registration with a practice may not make much difference for this group of patients. What are the other benefits of registration? </p>
<p><strong>2) Reducing hospital admissions</strong></p>
<p>Avoiding hospitals can be beneficial – in hospitals, there are no home comforts, they are inconvenient for you and relatives, there is little privacy, and they can be costly. Patients with ten or more hospital admissions in a year have been targeted as they have more complex chronic conditions and may be from vulnerable populations. </p>
<p>Better access to a GP could prevent patients visiting the emergency department or prevent overnight hospital admissions. Research shows financial incentives for GPs to better manage chronic disease <a href="https://journals.sagepub.com/doi/full/10.1177/01410768211005109">can reduce hospital admissions</a>. </p>
<p>However, <a href="https://bmjopen.bmj.com/content/5/4/e007342?cpetoc=&int_source=trendmd&int_medium=trendmd&int_campaign=trendmd">hospital admissions could also increase</a> if the scheme identifies significant levels of previous unmet need.</p>
<p><strong>3) Reducing barriers to care</strong></p>
<p>MyMedicare does not directly address many of the <a href="https://link.springer.com/article/10.1186/1475-9276-12-18">barriers to accessing GP services</a>. If GPs are getting paid more and still getting fee for service payments, will MyMedicare patients be guaranteed to be bulk billed? This has not yet been mentioned, but could be an important part of the scheme to attract patients. </p>
<p>People with chronic disease have <a href="https://grattan.edu.au/report/not-so-universal-how-to-reduce-out-of-pocket-healthcare-payments/">two to three times higher</a> out-of-pocket costs than those who do not, and <a href="https://healthsystemsustainability.com.au/the-voice-of-australian-health-consumers/">30%</a> of patients with chronic disease would find it difficult to pay for care if they became seriously ill. </p>
<p>Unfortunately MyMedicare will not directly reduce out-of-pocket costs, which may be the real reason why people use “free” emergency department care.</p>
<p><strong>4) Making it clear and easy to sign up</strong></p>
<p>It is also unclear how the process of registration will work for patients. Will patients be offered a choice of alternative GPs? If chosen, will GPs be obliged to take them? </p>
<p>At the moment, there are no public data about out-of-pocket costs and quality of care provided by different GPs, and so it will be impossible for patients to make an informed choice. Information to inform choice on a website would be useful, as is the case for <a href="https://www.health.gov.au/resources/apps-and-tools/medical-costs-finder">specialists</a>. </p>
<p>It’s also unclear if patients who chose to register will find it harder to move GPs or continue to see other GPs if they wish to. The advantages to patients of MyMedicare need to be made clear to encourage them to register and be supported to exercise informed choice if they wish.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/if-you-live-in-a-bulk-billing-desert-its-hard-to-see-a-doctor-for-free-heres-how-to-fix-this-204029">If you live in a bulk-billing ‘desert’ it's hard to see a doctor for free. Here's how to fix this</a>
</strong>
</em>
</p>
<hr>
<h2>Will it make a difference for GPs?</h2>
<p>Patient registration can mean a more secure and predictable stream of future income for some patients and also less competition (in terms of “losing” patients to other GPs) and more continuity of care. </p>
<p>Moving away from fee for service towards a blended payment model is <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011865.pub2/full">widely recognised</a> to support higher value health care. </p>
<p>Yet GPs are wary of moving from fee for service to capitation payment. Capitation payments are fixed, so GPs take on more financial risk if they have more complex patients who are more costly to treat and manage in terms of time and effort. Whether the $2,000, plus $500 bonus, plus normal fee for service payments are sufficient to cover the costs of treating very complex patients is unclear. </p>
<p>Overall, GPs will get more money, and along with the other announcements in the budget, will receive a significant investment of resources invested in primary care. </p>
<p>Our previous <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/hec.3572">research</a> has shown a 5% increase in earnings for GPs is predicted to reduce the total number of GPs by up to 1% (equivalent to around 310 GPs in 2021) at a time of significant GP shortages. If they get paid more, they would prefer to work less.</p>
<p>But this could also be offset because the increase in funding will hopefully make general practice more attractive as a career and so there will be more postgraduate doctors <a href="https://www.sciencedirect.com/science/article/pii/S0167629612000902">choosing to be a GP</a>. </p>
<p>Voluntary patient registration under MyMedicare has potential to strengthen the relationship between patients and their GP, and focuses on keeping patients out of hospital and properly cared for in residential aged care. But the devil is in the detail and we will need a proper evaluation to determine the impacts on health outcomes, costs and access to health care. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-if-medicare-was-restricted-to-gps-who-bulk-billed-this-kind-of-reform-is-possible-203543">What if Medicare was restricted to GPs who bulk billed? This kind of reform is possible</a>
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</em>
</p>
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<img src="https://counter.theconversation.com/content/206183/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Scott receives funding from the Australian Research Council, Medibank Better Health Foundation, and the Independent Hospital and Aged Care Pricing Authority.</span></em></p>MyMedicare is a new voluntary scheme that allows patients to register with their usual GP. How will it work? And how might it benefit patients? Here’s what we know so far.Anthony Scott, Professor of Health Economics, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2079102023-07-02T20:02:21Z2023-07-02T20:02:21ZExpensive dental care worsens inequality. Is it time for a Medicare-style ‘Denticare’ scheme?<figure><img src="https://images.theconversation.com/files/533361/original/file-20230622-27-i2qy62.jpg?ixlib=rb-1.1.0&rect=0%2C14%2C4920%2C3238&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/pain-armchair-dentist-suffering-52527/">Pixabay</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>There’s <a href="https://grattan.edu.au/wp-content/uploads/2023/06/A-growing-cavity-why-expanding-dental-coverage-is-increasingly-urgent.pdf">growing awareness</a> public dental programs are unable to meet the demand for services. Private dental care is increasingly unaffordable, and millions of Australians go without the treatment they need. </p>
<p>The <a href="https://www.canberratimes.com.au/story/8039058/years-of-pain-wait-times-for-public-dentist-appointments-blow-out/">potentially avoidable costs</a> to the health-care system and to people’s quality of life has led to <a href="https://www.abc.net.au/news/health/2019-03-18/calls-for-medicare-funded-dental-health-scheme-in-australia/10903574">increased pressure</a> for a Medicare-style universal insurance scheme for dental care (Denticare) or the inclusion of dental care into Medicare.</p>
<p>Affordable and available dental care is crucial to addressing inequality in Australia. Teeth and gum problems can affect everything from your life expectancy and general health to your job prospects. The “<a href="https://www.mja.com.au/journal/2014/201/11/closing-dental-divide">dental divide</a>” between rich and poor actually replicates disadvantage in Australian society. </p>
<p>So how did we get here? And what might change look like?</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-greens-want-medicare-to-cover-a-trip-to-the-dentist-its-a-grand-vision-but-short-on-details-181239">The Greens want Medicare to cover a trip to the dentist. It's a grand vision but short on details</a>
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</p>
<hr>
<h2>Why wasn’t dental included in Medicare in the first place?</h2>
<p>The prevailing wisdom is that when the Whitlam Government put Medibank (the precursor to Medicare) forward in 1974, dental care was not included because of <a href="https://johnmenadue.com/why-dental-care-was-excluded-from-medicare-and-why-it-should-now-be-included-an-edited-repost/">cost and politics</a> – the battle with doctors’ groups opposed the new health-care insurance plan was difficult enough without taking on dental groups too.</p>
<p>There is, however, little to no evidence on the extent to which the Whitlam government pushed for dental to be included or how much it was opposed by dentists. It seems it was not on the agenda when Medicare was restored by the Hawke government.</p>
<p>Financial issues aside, there are two likely reasons dental wasn’t included.</p>
<p>Firstly, medicine and dentistry remain <a href="https://www1.racgp.org.au/ajgp/2020/september/medicine-and-dentistry">isolated practices</a> that have never been treated the same way by the health-care system, health insurance funds, policymakers and the public. </p>
<p>Despite all the <a href="https://www.aihw.gov.au/reports/dental-oral-health/oral-health-and-dental-care-in-australia/contents/introduction">evidence</a> on the importance of oral health, too often it is seen as merely a “nice-to-have”.</p>
<p>Secondly, the provision of public dental health services – often linked to dental hospitals and dental schools – has long been seen (especially by <a href="https://www.smh.com.au/national/howard-lays-dental-blame-on-states-20061205-gdoz3t.html">Coalition governments</a>) as the responsibility of states and territories. These services have always been directed at children, low-income adults, and defined disadvantaged groups.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/533378/original/file-20230622-29-xr1bx2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/533378/original/file-20230622-29-xr1bx2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/533378/original/file-20230622-29-xr1bx2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533378/original/file-20230622-29-xr1bx2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533378/original/file-20230622-29-xr1bx2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533378/original/file-20230622-29-xr1bx2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533378/original/file-20230622-29-xr1bx2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533378/original/file-20230622-29-xr1bx2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A dental check-up shouldn’t cost the Earth.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/man-in-gray-shirt-having-dental-check-up-3845807/">Anna Shvets/Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>A short history</h2>
<p>Section 51(xxiiiA) of the Australian Constitution, added in 1946, accords dental services the <a href="https://www.aph.gov.au/parliamentary_business/committees/senate/community_affairs/completed_inquiries/1996-99/dental/report/c04">same status as medical services</a>. This section gives the Commonwealth the power to legislate and fund these services but it’s not obligated to do so.</p>
<p>The Whitlam government was the first to provide national funding and direction to these state-based programs through the <a href="https://parlinfo.aph.gov.au/parlInfo/download/library/prspub/75IR6/upload_binary/75ir60.pdf%3BfileType=application/pdf#search=%2522library/prspub/75IR6%2522">Australian School Dental Program</a>. </p>
<p>Under the Keating government, the Commonwealth took a more substantial role in the funding of dental services with the introduction of the <a href="https://parlinfo.aph.gov.au/parlInfo/download/library/prspub/75IR6/upload_binary/75ir60.pdf%3BfileType=application/pdf#search=%2522library/prspub/75IR6%2522">Commonwealth Dental Health Program</a>, directed at financially disadvantaged adults. </p>
<p>This began in January 1994 but was abolished by the Howard government in 1996. </p>
<p>The Gillard government introduced National Partnership Agreements for Public Dental Services for Adults, which currently provide <a href="https://federalfinancialrelations.gov.au/sites/federalfinancialrelations.gov.au/files/2023-03/Public%20Dental%20Services%20for%20Adults%20-%202022-23.pdf">A$107.8 million annually</a> to the states and territories.</p>
<h2>The barriers to universal dental care</h2>
<p>Proposals to expand Medicare to include dental services have been variously estimated to cost between $5.6 billion in additional Commonwealth spending per year (according to the <a href="https://grattan.edu.au/wp-content/uploads/2019/03/915-Filling-the-gap-A-universal-dental-scheme-for-Australia.pdf">Grattan Institute</a>) and $7.5 billion a year (according to <a href="https://www.theguardian.com/australia-news/2022/apr/12/billionaire-tax-to-fund-greens-75bn-plan-for-medicare-to-cover-dental">The Greens’ 2022 election policy</a>).</p>
<p>These figures don’t factor in the savings made to health-care costs due to preventable dental cavities and gum disease (estimated by the Australian Dental Association at <a href="https://www.ada.org.au/ADHP">$818 million per year</a>) and reduced productivity. Nevertheless, this is a huge budget impost. It would require increases in the Medicare levy, and/or increased taxation and/or cuts to the private health insurance rebate.</p>
<p>The other approach is to reduce costs by limiting the number of people covered and/or the number and type of services covered.</p>
<p>Means testing access to Medicare Benefits Schedule items for dental care is risky; it could easily lead to means testing of access to other MBS items. </p>
<p>Limiting the type of services covered is possible but would require a huge amount of work and endless debate on what constitutes basic and necessary services.</p>
<p>The establishment of an entirely separate scheme (the Denticare model) will still require enormous amounts of evidence-based decision-making around who and what is covered, how this is paid for, and what subsequently happens to current federally- and state-funded dental programs.</p>
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<h2>There’s more we can do</h2>
<p>Previous attempts to incorporate dental services into Medicare have arguably failed. Researchers have described the Chronic Dental Disease Scheme (introduced by the Howard government) <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3494828/">as</a> as “the most expensive and controversial public dental policy in Australian history”. As a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3494828/">2012 analysis</a> showed, it blew out its budget and did not result in dental health improvements.</p>
<p>The current Child Dental Benefits Schedule has a <a href="https://www.anao.gov.au/work/performance-audit/administration-child-dental-benefits-schedule">low uptake</a>. Less than <a href="https://www.ada.org.au/News-Media/News-and-Release/Latest-News/Have-your-say-on-the-Child-Dental-Benefits-Schedul">40%</a> of those eligible for the scheme actually use it.</p>
<p>As I <a href="https://theconversation.com/how-to-fill-the-gaps-in-australias-dental-health-system-35371">wrote</a> in 2014, there is plenty Australia could do to better integrate dental and medical care, including focusing on best-value investments such as fluoridation and preventive services. It’s worth noting many of the preventive actions needed to address <a href="https://www.dentalnews.com/2019/07/25/is-there-a-link-between-obesity-and-oral-health/">obesity</a> (for example, encouraging breast feeding and limiting sugary beverages) will also improve dental health.</p>
<p>We could also expand emergency dental services in hospital emergency departments and create a “Dental Health Service Corps” of dentists and other medical professionals to help in rural and remote areas.</p>
<p>Almost a decade later, little as been done. Sadly, in the many years I’ve been writing about the <a href="https://www.mja.com.au/journal/2014/201/11/closing-dental-divide">dental divide</a>, the only movement I’ve seen is in the increasingly bad numbers around waiting lists and costs to patients.</p>
<p>A Senate Select Committee is currently conducting yet another <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Dental_Services_in_Australia/DentalServices">inquiry into dental services</a> in Australia. Its just-released <a href="https://parlinfo.aph.gov.au/parlInfo/download/committees/reportsen/RB000080/toc_pdf/Interimreport.pdf">interim report</a>, which discussed some of the proposals heard so far by the committee and some possible questions for it to consider, described Australia’s current oral and dental health system as “broken”. Public hearings, which will inform the committee’s final report, will be held later in the year.</p>
<p>Hopefully, this inquiry will (finally) drive politicians to see dental care as essential to health, wellbeing and a fair society – and to act.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-fill-the-gaps-in-australias-dental-health-system-35371">How to fill the gaps in Australia's dental health system</a>
</strong>
</em>
</p>
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<img src="https://counter.theconversation.com/content/207910/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lesley Russell worked for the federal Australian Labor Party as a policy advisor from 2001 to 2007.</span></em></p>Affordable and available dental care is crucial to addressing inequality in Australia.Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2064622023-06-01T12:31:37Z2023-06-01T12:31:37ZGetting Social Security on a more stable path is hard but essential – 2 experts suggest a way forward<figure><img src="https://images.theconversation.com/files/528714/original/file-20230528-19-7mz301.jpg?ixlib=rb-1.1.0&rect=54%2C39%2C5166%2C3475&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">No big Social Security reforms have taken effect since the Reagan administration.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/president-reagan-speaks-before-signing-the-social-security-news-photo/568872063">David Hume Kennerly/Getty Images</a></span></figcaption></figure><p>Social Security is in trouble. </p>
<p>The retirement and disability program has been running a cash-flow deficit since 2010. Its trust fund, which holds US$2.7 trillion, is rapidly diminishing. Social Security’s trustees, a group that includes the secretaries of the departments of Treasury, Labor, and Health and Human Services, as well as the Social Security commissioner, project that the trust fund will be <a href="https://www.ssa.gov/OACT/TR/2023/tr2023.pdf">completely drained by 2033</a>. </p>
<p>Under current law, when that trust fund is empty, Social Security can pay benefits only from dedicated tax revenues, which would by that point cover about <a href="https://www.ssa.gov/OACT/TRSUM/tr23summary.pdf">77% of promised benefits</a>. Another way to say this is that when the trust fund is depleted, under current law, Social Security beneficiaries would see a sudden 23% cut in their monthly checks in 2034. </p>
<p><a href="https://scholar.google.com/citations?hl=en&user=CwMgD5QAAAAJ">As economists</a> who <a href="https://scholar.google.com/citations?user=y0lrTOoAAAAJ&hl=en&oi=ao">study the Medicare and Social Security programs</a>, we view the above scenario as politically unacceptable. Such a sudden and dramatic benefit cut would anger a lot of voters. Unfortunately, the actions necessary now to avoid it – like raising taxes or cutting benefits – aren’t getting serious consideration today. But we believe there are strategies that could work.</p>
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<h2>Where the money for benefits comes from</h2>
<p>Roughly <a href="https://www.ssa.gov/news/press/factsheets/basicfact-alt.pdf">67 million Americans, most of whom are 65 or older</a>, receive Social Security benefits. The agency <a href="https://www.ssa.gov/news/press/releases/2021/#8-2021-2">disburses more than $1 trillion annually</a>. It’s the government’s largest single expenditure, constituting nearly <a href="https://fiscaldata.treasury.gov/americas-finance-guide/federal-spending/">20% of the total federal budget</a>.</p>
<p><a href="https://www.ssa.gov/oact/progdata/taxRates.html">Social Security is funded</a> by a payroll tax of 12.4% on wages split equally between workers and employers. Self-employed people pay the entire 12.4%. This payroll tax applies to earnings up to $160,200 as of 2023. The government increases this cap annually based on increases in the <a href="https://www.investopedia.com/terms/n/national-average-wage-index-nawi.asp">National Average Wage Index</a> – a measure that combines wage growth and inflation. The program also receives about 4% of its revenue from a <a href="https://www.ssa.gov/OACT/TR/2023/tr2023.pdf">tax on Social Security benefits</a>, though not everyone who receives them has to pay this tax.</p>
<p>Social Security tax revenue stayed relatively flat after 1990. But the costs of the program rose sharply in 2010, in part because of early <a href="https://doi.org/10.1177/0002716213499535">retirements in response to the Great Recession</a>.</p>
<p>Social Security spending has recently been growing more rapidly because of a <a href="https://www.pewresearch.org/short-reads/2020/11/09/the-pace-of-boomer-retirements-has-accelerated-in-the-past-year/">wave of baby boomer retirements</a>, which added to a decline in the <a href="https://retirementincomejournal.com/article/does-social-security-use-the-wrong-dependency-ratio">number of workers per retiree</a>.</p>
<p>Costs of the program are expected to further exceed the money that’s coming in, which will <a href="https://www.ssa.gov/OACT/TR/2023/tr2023.pdf">continue to drain the trust fund</a>, according to the program’s trustees. </p>
<p>Barring immediate action by the government, the trust fund’s exhaustion is only a little more than a decade away. And yet few members of Congress seem willing to do something about it. For example, <a href="https://thehill.com/homenews/sunday-talk-shows/3835082-mccarthy-social-security-medicare-cuts-off-the-table/">Social Security reform was not even</a> on the table during the 2023 negotiations over the debt ceiling and spending cuts.</p>
<h2>Trust fund</h2>
<p>Where did the trust fund, which helps cover the program’s costs, come from?</p>
<p>While the Social Security program was collecting surpluses from 1984 to 2009, that extra money funded other spending – keeping other taxes lower than they would have been otherwise and <a href="https://www.whitehouse.gov/omb/budget/historical-tables/">partially covering the budget deficit</a>.</p>
<p>During Social Security’s years of surplus, the excess revenues were credited to the trust fund in the form of <a href="https://www.ssa.gov/oact/progdata/specialissues.html">special-issue government bonds</a> that yielded the prevailing interest rates. When those bonds are needed to pay for Social Security expenses, the Treasury redeems them.</p>
<p>Those bonds are components of the <a href="https://www.crfb.org/papers/qa-gross-debt-versus-debt-held-public">government’s $31.4 trillion gross debt</a>. </p>
<h2>Last reformed during the Reagan administration</h2>
<p>Reducing the benefits current retirees receive would be extremely unpopular. Likewise, people now in the workforce who are nearing retirement would certainly object strongly if they were told to expect lower benefits in retirement than they have been promised throughout their careers.</p>
<p>The last time the government made big changes to Social Security was in 1983, during the Reagan administration, when the government enacted reforms that <a href="https://www.ssa.gov/history/1983amend.html">slowly reduced benefits over time</a>. These changes included raising the full retirement age, a change that is <a href="https://www.ssa.gov/benefits/retirement/planner/agereduction.html">still being phased in</a>. Because of those changes, workers born in 1960 or later cannot retire with full benefits until age 67 – two years later than the original retirement age.</p>
<p>The 1983 reforms also included increases in the Social Security payroll tax rate from 10.4% in 1983 to 12.4% by 1990, and for the first time levied federal income taxes on higher-income retirees’ benefits. Workers bore the burden of the payroll tax increases and <a href="https://faq.ssa.gov/en-us/Topic/article/KA-02471">higher-income retirees bore the burden of the tax on benefits</a>.</p>
<p>Those changes bolstered the program’s finances, but they no longer suffice.</p>
<p>The bipartisan <a href="https://www.ssa.gov/history/reports/pcsss/pcsss.html">2001 Commission to Strengthen Social Security</a> tried – and failed – during George W. Bush’s presidency to get Congress to enact reforms to shore up the program’s finances. There’s been no momentum toward resolving the problem since then.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/529392/original/file-20230531-27-mc2adl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man with gray hair sits at a table in front of a giant replica of a Social Security card." src="https://images.theconversation.com/files/529392/original/file-20230531-27-mc2adl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/529392/original/file-20230531-27-mc2adl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/529392/original/file-20230531-27-mc2adl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/529392/original/file-20230531-27-mc2adl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/529392/original/file-20230531-27-mc2adl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=496&fit=crop&dpr=1 754w, https://images.theconversation.com/files/529392/original/file-20230531-27-mc2adl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=496&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/529392/original/file-20230531-27-mc2adl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=496&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">George W. Bush sought to reform Social Security early in his presidency.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/george-bush-speaks-about-social-security-during-a-news-photo/525606778">Brooks Kraft LLC/Sygma via Getty Images</a></span>
</figcaption>
</figure>
<h2>4 principles</h2>
<p>We believe that policymakers and lawmakers need to follow four principles as they consider how to move forward.</p>
<ol>
<li><p>The program should be self-funded in the long run so that its annual revenues match its annual expenses. That way the many questions that arise related to trust fund accounting and whether Social Security tax revenues are being used for their intended purposes would be eliminated. </p></li>
<li><p>The reform burden should be shared across generations. Current retirees can share the burden through a reform that reduces the cost-of-living adjustment. Today’s workers can share the burden through an increase in the cap on income subjected to Social Security taxes so that 90% of total earnings are taxed. Continued gradual increases in the retirement age to keep pace with <a href="https://www.cbo.gov/system/files/2022-07/57975-demographic-outlook.pdf">anticipated longevity gains</a> would also be borne by current workers. </p></li>
<li><p>The government should make sure that Social Security benefits will be adequate for lower-income retirees for years to come. That means reforms that slow the benefit growth of future retirees would be designed to affect only higher-income retirees. </p></li>
<li><p>Any changes to Social Security should help constrain the future growth of federal spending, given the <a href="https://www.cbo.gov/publication/58946#_idTextAnchor004">current and projected growth in the budget deficit</a>.</p></li>
</ol>
<h2>Advantages of ending the delay</h2>
<p>It appears that the U.S. – citizens and elected officials included – are deferring serious debate on this urgent matter until the trust fund’s depletion is imminent. That’s unwise. Acting sooner rather than later would leave more options available to gradually resolve the program’s financial shortfalls. </p>
<p>Ending this procrastination would also give the millions of people who rely on Social Security benefits, taxpayers and businesses more time to prepare for any changes required by overdue reforms.</p><img src="https://counter.theconversation.com/content/206462/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Rettenmaier does not work for, consult, or own shares in or receive funding from any company or organization that would benefit from this article. He has received funding from the American Enterprise Institute, the Bradley Foundation, the Charles Koch Foundation, and the National Center for Policy Analysis. </span></em></p><p class="fine-print"><em><span>Dennis W. Jansen does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>If Congress and the White House fail to take action, Social Security beneficiaries would see a sudden 23% cut in their monthly checks in 2034.Andrew Rettenmaier, Executive Associate Director of the Private Enterprise Research Center, Texas A&M UniversityDennis W. Jansen, Professor of Economics and Director of the Private Enterprise Research Center, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2051652023-05-10T18:49:55Z2023-05-10T18:49:55ZWhat does ending the emergency status of the COVID-19 pandemic in the US mean in practice? 4 questions answered<figure><img src="https://images.theconversation.com/files/524939/original/file-20230508-197326-1kuk6o.jpg?ixlib=rb-1.1.0&rect=181%2C142%2C8465%2C5418&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">COVID-19 hasn't vanished, but at this point it's doing less damage.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/woman-erasing-red-covid-19-virus-with-paint-roller-royalty-free-image/1292684629?phrase=covid-19&adppopup=true">Klaus Vedfelt/DigitalVision via Getty Images</a></span></figcaption></figure><p><em>The COVID-19 pandemic’s public health emergency status in the U.S. <a href="https://www.npr.org/2023/04/11/1169191865/biden-ends-covid-national-emergency">expires on May 11, 2023</a>. And on May 5, the World Health Organization declared <a href="https://www.statnews.com/2023/05/05/who-declares-end-to-covid-global-health-emergency/?">an end to the COVID-19 public health emergency of international concern</a>, or PHEIC, designation that had been in place since Jan. 30, 2020.</em> </p>
<p><em>Still, both the WHO and the White House have made clear that while the emergency phase of the pandemic has ended, the virus is here to stay and <a href="https://www.washingtonpost.com/health/2023/05/05/covid-forecast-next-two-years/">could continue to wreak havoc</a>.</em> </p>
<p><em>WHO Director General Tedros Adhanom Ghebreyesus noted that, over that time, the virus has taken the lives of <a href="https://www.washingtonpost.com/world/2023/05/05/who-covid-global-health-emergency/">more than 1 million people in the U.S.</a> and <a href="https://doi.org/10.1038/d41586-023-01559-z">about 7 million people globally</a> based on reported cases, though he said the true toll is likely <a href="https://www.npr.org/sections/goatsandsoda/2023/05/05/1174269442/who-ends-global-health-emergency-declaration-for-covid-19">closer to 20 million people worldwide</a>. While the global emergency status has ended, COVID-19 is still an “<a href="https://www.who.int/news/item/05-05-2023-statement-on-the-fifteenth-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-coronavirus-disease-(covid-19)-pandemic">established and ongoing health issue</a>,” he said.</em></p>
<p><em>The Conversation asked public health experts <a href="https://cph.osu.edu/people/mjones">Marian Moser Jones</a> and <a href="https://cph.osu.edu/people/afairchild">Amy Lauren Fairchild</a> to put these changes into context and to explain their ramifications for the next stage of the pandemic.</em> </p>
<h2>1. What does ending the national emergency phase of the pandemic mean?</h2>
<p>Ending the federal emergency reflects both a scientific and political judgment that the acute phase of the COVID-19 pandemic crisis has ended and that special federal resources are no longer needed to prevent disease transmission across borders. </p>
<p>In practical terms, it means that two declarations – the <a href="https://www.phe.gov/emergency/news/healthactions/phe/Pages/2019-nCoV.aspx">federal Public Health Emergency</a>, first declared on Jan. 31, 2020, and the <a href="https://www.whitehouse.gov/briefing-room/presidential-actions/2022/02/18/notice-on-the-continuation-of-the-national-emergency-concerning-the-coronavirus-disease-2019-covid-19-pandemic-2/">COVID-19 national emergency</a> that former President Donald Trump announced on March 13, 2020, are expiring.</p>
<p>Declaring those emergencies enabled the federal government to cut through mountains of red tape to respond to the pandemic more efficiently. For instance, the declarations allowed <a href="https://aspr.hhs.gov/legal/PHE/Pages/Public-Health-Emergency-Declaration.aspx">funds to be made available</a> so that federal agencies could direct personnel, equipment, supplies and services to state and local governments wherever they were needed. In addition, the declarations made funding and other resources available to launch investigations into the “<a href="https://aspr.hhs.gov/legal/PHE/Pages/Public-Health-Emergency-Declaration.aspx">cause, treatment or prevention</a>” of COVID-19 and to enter into contracts with other organizations to meet needs stemming from the emergency. </p>
<p>The emergency status also allowed the federal government to make health care more widely available by <a href="https://aspr.hhs.gov/legal/PHE/Pages/Public-Health-Emergency-Declaration.aspx">suspending many requirements</a> for accessing Medicare, Medicaid and the Children’s Health Program, or CHIP. And they made it possible for people to receive free COVID-19 testing, treatment and vaccines and <a href="https://www.medicaid.gov/medicaid/benefits/downloads/medicaid-telehealth-services.pdf">enabled Medicaid</a> and Medicare to <a href="https://telehealth.hhs.gov/providers/billing-and-reimbursement/">more easily cover telehealth services</a>. </p>
<p>Finally, the Trump administration used the national emergency to invoke <a href="https://www.dhs.gov/news/2023/01/05/dhs-continues-prepare-end-title-42-announces-new-border-enforcement-measures-and">Title 42</a>, a section of the Public Health Service Act that allows the federal government to <a href="https://theconversation.com/a-trump-era-law-used-to-restrict-immigration-is-nearing-its-end-despite-gop-warnings-of-a-looming-crisis-at-the-southern-border-194971">stop people at the nation’s borders</a> to prevent introduction of communicable diseases. Asylum seekers and others who normally undergo processing when they enter the U.S. have been turned away under this rule. </p>
<h2>2. What domestic policies are changing?</h2>
<p>An estimated 15 million people are likely to lose Medicaid or CHIP coverage, <a href="https://aspe.hhs.gov/sites/default/files/documents/a892859839a80f8c3b9a1df1fcb79844/aspe-end-mcaid-continuous-coverage.pdf">according to the federal government</a>. <a href="https://www.kff.org/medicaid/issue-brief/how-many-people-might-lose-medicaid-when-states-unwind-continuous-enrollment/">Another analysis projected</a> that as many as 24 million people will be kicked off the Medicaid rolls.</p>
<p>Before the pandemic, states required people to prove every year that they met income and other eligibility requirements. This <a href="https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-growth-estimates-by-state-and-eligibility-group-show-who-may-be-at-risk-as-continuous-enrollment-ends/">resulted in “churning”</a> – a process whereby people who did not complete renewal paperwork were being periodically disenrolled from state Medicaid programs before they could reapply and prove eligibility. </p>
<p>In March 2020, Congress enacted a continuous enrollment provision in Medicaid that prevented states from removing anyone from their rolls during the pandemic. From February 2020 to March 31, 2023, <a href="https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-growth-estimates-by-state-and-eligibility-group-show-who-may-be-at-risk-as-continuous-enrollment-ends/">enrollment in Medicaid and CHIP grew by nearly 23.5%</a> to a total of more than 93 million. In a December 2022 appropriations bill, Congress passed a provision that ended continuous enrollment on March 31, 2023.</p>
<p>The Biden administration <a href="https://www.whitehouse.gov/wp-content/uploads/2023/01/SAP-H.R.-382-H.J.-Res.-7.pdf">defended this time frame as sufficient</a> to ensure that patients did not “lose access to care unpredictably” and that state Medicaid budgets – which received emergency funds beginning in 2020 – didn’t “face a radical cliff.” </p>
<p>But many people who have Medicaid or who enrolled their children in CHIP during this period may be unaware of these changes until they actually lose their benefits over the next several months.</p>
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<p>At least five states already <a href="https://ccf.georgetown.edu/2023/04/01/state-unwinding-tracker/">began disenrolling Medicaid members in April</a>. Other states are <a href="https://medicaid.ohio.gov/stakeholders-and-partners/covidunwinding/covidunwinding">sending out termination letters</a> and <a href="https://www.hhs.texas.gov/services/health/medicaid-chip/end-continuous-medicaid-coverage">renewal notices</a> and will <a href="https://ccf.georgetown.edu/2023/04/01/state-unwinding-tracker/">disenroll members starting in May, June and July</a>.</p>
<p>Only Oregon has set up a comprehensive program to minimize disenrollments. That state is running a <a href="https://www.oregon.gov/oha/HSD/Medicaid-Policy/Documents/2022-2027-1115-Demonstration-Approval.pdf">five-year federal demonstration program</a> that allows it to temporarily let people stay on Medicaid if their income is up to 200% of the federal poverty level and lets eligible children stay on Medicaid through age 6. Many other states are <a href="https://www.medicaid.gov/covid-19-phe-unwinding-section-1902e14a-waiver-approvals/index.html">trying more limited strategies</a> to improve the renewal process and decrease churning.</p>
<p>The array of telehealth services that Medicare began <a href="https://telehealth.hhs.gov/providers/billing-and-reimbursement/billing-and-coding-medicare-fee-for-service-claims/?">covering during the pandemic</a> will continue to be covered through December 2024. Medicare is also making coverage for <a href="https://telehealth.hhs.gov/providers/policy-changes-during-the-covid-19-public-health-emergency/policy-changes-after-the-covid-19-public-health-emergency">behavioral and mental telehealth services a permanent benefit</a>.</p>
<p>The end of the emergency also means that the federal government is no longer covering the costs of COVID-19 vaccines and treatments for everyone. However, in April, the Biden administration announced a new $1.1 billion <a href="https://www.hhs.gov/about/news/2023/04/18/fact-sheet-hhs-announces-hhs-bridge-access-program-covid-19-vaccines-treatments-maintain-access-covid-19-care-uninsured.html">public-private “bridge access program</a>” that will provide COVID-19 vaccines and treatments free of charge for uninsured people through state and local health departments and pharmacies. Insured individuals may have out-of-pocket costs depending on their coverage.</p>
<p>The end of the emergency lifts the pandemic restriction on border crossing. Large numbers of migrants <a href="https://www.cnn.com/2023/05/08/us/title-42-expires-border-immigration/index.html">have gathered at the Mexico-U.S. border</a> and are expected to enter the country in the coming weeks, further straining already overwhelmed staff and facilities. </p>
<h2>3. What does this mean for the status of the pandemic?</h2>
<p><a href="https://www.ncbi.nlm.nih.gov/books/NBK143061">A pandemic declaration</a> represents an assessment that human transmission of a disease, whether well known or novel, is “extraordinary,” that it constitutes a public health risk to two or more U.S. states and that controlling it requires an international response. But declaring an end to the emergency doesn’t mean a return to business as usual.</p>
<p><a href="https://www.who.int/publications/i/item/WHO-WHE-SPP-2023.1">New global guidelines for long-term disease management</a> of COVID-19, released on May 3, 2023, urged countries “to maintain sufficient capacity, operational readiness and flexibility to scale up during surges of COVID-19, while maintaining other essential health services and preparing for the emergence of new variants with increased severity or capacity.”</p>
<p>Former White House COVID-19 response coordinator <a href="https://fortune.com/well/2023/04/29/covid-antiviral-paxlovid-evade-deborah-birx-double-deaths/">Deborah Birx recently warned</a> that the omicron COVID-19 variant continues to mutate and may become resistant to existing treatments. She called for more federally funded research into therapeutics and durable vaccines that protect against many variants. </p>
<p>Birx’s warnings come as <a href="https://www.krem.com/article/news/health/coronavirus/washington-covid-final-press-conference/293-3f109a05-5e8a-4c80-8868-18f8cd9d3fbe">remaining states have ended their COVID-19 press briefings</a> and <a href="https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/CANotify/CANotifyMain.aspx">shut down their exposure notification systems</a>, and the <a href="https://apnews.com/article/covid-home-test-78960c4c36422907a2eab3eb0dcdfadd">federal government has ended its free COVID-19 at-home test program</a>. </p>
<p>With the end of the emergency, the CDC is also changing the way it presents its COVID-19 data to a “<a href="https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html">sustainable national COVID-19 surveillance” model</a>. This shift in COVID-19 monitoring and communication strategies accompanying the end of the emergency means that the virus is disappearing from the headlines, even though it has not disappeared from our lives and communities.</p>
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<h2>4. How will state and local pandemic measures be affected?</h2>
<p>The end of the federal emergency does not affect state-level or local-level emergency declarations. These declarations have allowed states to allocate resources to meet pandemic needs and have <a href="https://telehealth.hhs.gov/providers/policy-changes-during-the-covid-19-public-health-emergency/telehealth-licensing-requirements-and-interstate-compacts/">included provisions</a> allowing them to respond to surges in COVID-19 cases by allowing out-of-state physicians and other health care providers to practice in person and through telehealth. </p>
<p>Most U.S. states, however, have ended their own public health emergency declarations. Six states – Delaware, Illinois, Massachusetts, New York, Rhode Island and Texas – still had emergency declarations in effect as of May 3, 2023, that will expire by the end of the month. So far, <a href="https://nashp.org/states-covid-19-public-health-emergency-declarations/">Massachusetts Gov. Maura Healey</a> stands alone in having indicated that she will “extend key flexibilities provided by the public health emergency” related to health care staffing and emergency medical services.</p>
<p>While some states may choose to make permanent some COVID-era emergency standards, such as looser restrictions on telemedicine or out-of-state health providers, we believe it could be a long time before either politicians or members of the public regain an appetite for any emergency orders directly related to COVID-19. </p>
<p><em>This is an updated version of an article that was <a href="https://theconversation.com/bidens-plan-for-ending-the-emergency-declaration-for-covid-19-signals-a-pivotal-point-in-the-pandemic-4-questions-answered-199060">originally published</a> on Feb. 3, 2023.</em></p><img src="https://counter.theconversation.com/content/205165/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marian Moser Jones receives funding from the National Endowment for the Humanities and The American Public Health Association. In the past she has received funding from the National Institutes of Health and the American Association for the History of Nursing, as well as the State of Maryland.</span></em></p><p class="fine-print"><em><span>Amy Lauren Fairchild has received funding from NIH, NSF, NEH, the RWJ Foundation, and the Greenwall Foundation. </span></em></p>The emergency status allowed the federal government to cut through a mountain of red tape, with the goal of responding to the pandemic more efficiently.Marian Moser Jones, Associate Professor of Health Services Management, Policy and History, The Ohio State UniversityAmy Lauren Fairchild, Dean and Professor of Public Health, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2045272023-05-09T23:01:37Z2023-05-09T23:01:37ZHealth budget has big changes – reviving our worn-out Medicare fee-for-service system and boosting bulk billing<p>There were four major changes for <a href="https://www.health.gov.au/resources/collections/budget-2023-24">health care in the 2023-24 budget</a>: prioritising primary care, funding to strengthen Medicare, cheaper access to common medicines, and new funding to keep the digital health system going. Many of these changes were <a href="https://federation.gov.au/national-cabinet/media/2023-04-28-strengthening-medicare">foreshadowed in recent weeks</a>.</p>
<p>The big news on budget night was a tripling of the bulk-billing incentive, a key plank to strengthen Medicare. </p>
<p>This payment was <a href="https://journals.sagepub.com/doi/abs/10.1258/1355819042349899?journalCode=hsrb">introduced in 2004</a> to encourage GPs to bulk bill pensioners, health care card holders and children. It provides an additional amount, of <a href="http://www9.health.gov.au/mbs/search.cfm?q=10990&sopt=I">around A$7</a> to <a href="http://www9.health.gov.au/mbs/search.cfm?q=10991&sopt=I">over $10</a> depending on GP location, on top of the ordinary Medicare rebate when the service is bulk billed. </p>
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<p>But bulk billing has since declined, from about 90% of attendances in early 2022 to <a href="https://www.health.gov.au/resources/publications/medicare-quarterly-statistics-state-and-territory-december-quarter-2022-23?language=en">about 80% a year later</a>. Bulk billing is unevenly distributed and in some low-income areas (<a href="https://theconversation.com/if-you-live-in-a-bulk-billing-desert-its-hard-to-see-a-doctor-for-free-heres-how-to-fix-this-204029">bulk-billing deserts</a>) fewer than 50% of people have all their GP attendances bulk billed. This causes uncertainty and people missing out on care.</p>
<p>A tripling of the bulk-billing incentive – described as the biggest investment in Medicare in 40 years – is hoped to stem, and possibly reverse, the decline. </p>
<p>However it’s unclear whether it will increase bulk billing. Practice owners could simply pocket the increased incentive for patients who are already bulk billed, leaving bulk billing rates unchanged. Or GPs could use the increased revenue from their existing bulk-billed patients to <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/hec.3572">reduce their hours of work</a>, rather than bulk billing more patients.</p>
<h2>1. Primary care is now a priority</h2>
<p>The most important change in the budget for health was symbolic: the government talked about primary care. Typically, health budgets are focused on hospitals, with primary care an afterthought, or worse: the target of budget cuts. </p>
<p>The 2023 budget starts the process of the primary care rebuild, modernising the system in response to the transition to a population with more people with multiple chronic conditions, such as diabetes, heart disease and depression.</p>
<p>In the lead up to the budget, Health Minister Butler <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-care-speech-national-press-club-2-may-2023?language=en">emphasised the centrality of primary care</a> to the health system. In addition to the rhetoric, this budget allocates real money to create a new foundation for primary care.</p>
<h2>2. Funding the plan to strength Medicare</h2>
<p>The second change is to fund what has been long discussed. Health Minister Butler signalled the focus on primary care as one of his first acts when he appointed the <a href="https://www.health.gov.au/committees-and-groups/strengthening-medicare-taskforce">Strengthening Medicare Taskforce</a>, which I was a member of. </p>
<p>The <a href="https://www.health.gov.au/resources/publications/strengthening-medicare-taskforce-report?language=en">taskforce report</a>, released late last year, sets out an ambitious blueprint for change. This budget includes the first down payment, of more than $1 billion new money in a full year. </p>
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<a href="https://theconversation.com/new-medicare-reforms-wont-fix-everything-but-they-start-to-tackle-the-systems-biggest-problems-204800">New Medicare reforms won't fix everything but they start to tackle the system's biggest problems</a>
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<p>A key challenge for primary care policy is the reliance on fee-for-service payments. The budget addresses this by modernising the way the government pays for primary care in two critical ways:</p>
<p><strong>Patient enrolment</strong> </p>
<p>First, it introduces the concept of enrolment into the Australian primary care world. </p>
<p>Long part of primary care systems internationally, and regarded as one of the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3948764/">key “building blocks” for good primary care</a>, enrolment involves a patient identifying a preferred GP as their main source of care. </p>
<p>Patient enrolment, dubbed MyMedicare, will mean the practice or GP has responsibility for the patient between visits, and therefore introduces a long-term relationship between patient and practitioner.</p>
<p><strong>Team-based health care</strong></p>
<p>The Strengthening Medicare Taskforce also recommended more multi-disciplinary or team-based primary care, involving nurses, physiotherapists and a range of other health providers and administrative supports. This is a somewhat back-to-the-future initiative as the 21st-century iteration of the <a href="https://www.sydney.edu.au/news-opinion/news/2014/11/05/whitlam--medibank-and-health-system-reform.html">Whitlam government’s community health program</a>.</p>
<p>The budget provides a significant increase in the <a href="https://www.health.gov.au/our-work/workforce-incentive-program">workforce incentive program</a>, which provides grants to practices to employ nurses, Aboriginal and Torres Strait Islander health workers and allied health professionals. </p>
<p>The program recognises that care for people with multiple chronic conditions requires the skills of a range of professions. Importantly, many general practices have already recognised this and are already providing team-based care.</p>
<p>The increased funding in this budget will reward that past behaviour, making these practices more viable, as well as encouraging an expansion in other practices.</p>
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<img alt="Clinician takes an elderly man's blood pressure with a machine" src="https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/525060/original/file-20230509-19-7udzig.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The changes emphasise team-based care, using the skills of a range of health providers.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/elderly-man-having-blood-pressure-check-2246991347">Shutterstock</a></span>
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<h2>3. Extended prescription dispensing length</h2>
<p>The third budget change, <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-care-press-conference-26-april-2023?language=en">announced in April</a>, reduces prescription costs for medications by extending prescription quantities to two rather than one month’s supply for many common medications. </p>
<p>Despite <a href="https://www.smh.com.au/business/small-business/chemists-cry-poor-after-the-cornucopia-of-covid-19-20230427-p5d3nr.html">the tears and histrionics</a> of the Pharmacy Guild – the lobby group of pharmacy owners – the expert <a href="https://www.pbs.gov.au/industry/listing/elements/pbac-meetings/pbac-outcomes/2018-08/Increased-Dispensing-Quantity-List-of-Medicines-8-April-2019.pdf">Pharmaceutical Benefits Advisory Committee</a> recommended this modest change five years ago. </p>
<p>It doubles the amount of medication that may be dispensed under a single prescription, reducing patient co-payments and dispensing fees paid to pharmacists. It reduces government outlays by about $400 million a year and shows the government is prepared to take on a powerful stakeholder, despite the guild’s threats, <a href="https://www.afr.com/politics/federal/anthony-pratt-donates-nearly-4m-to-major-parties-20230130-p5cgn2">big political donations</a> and local campaigns. </p>
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<h2>4. Digital health time bomb</h2>
<p>Finally, the budget addresses a time bomb left by the previous government: digital health. </p>
<p>The Strengthening Medicare Taskforce identified contemporary digital health capacity as essential for a modern health system. Yet peculiarly, the previous government did not provide funding for the Digital Health Agency and My Health Record on an ongoing basis. It was due to expire on June 30 2023. </p>
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Read more:
<a href="https://theconversation.com/my-health-record-is-meant-to-empower-patients-but-with-little-useful-information-stored-is-it-worth-saving-199508">My Health Record is meant to empower patients – but with little useful information stored, is it worth saving?</a>
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<p>Some $250 million has been allocated in a full year <a href="https://www.medicalrepublic.com.au/whats-new-is-old-is-new-again-in-budget/91016">simply to keep the lights on and My Health Record ticking over</a>. </p>
<p>Although the current functionality and support for My Health Record leaves much to be desired, closing it down without replacement was never an option.</p>
<h2>What’s missing?</h2>
<p>The obvious omission relates to mental health. Although funding has been provided for more budget time bombs – programs which otherwise would have ended – and funding for additional places in psychology courses, mental health reform is still a work in progress.</p>
<p>The discontinuation of the COVID-related temporary extension of the Better Access program from a limit of ten to a limit of 20 mental health visits prompted <a href="https://theconversation.com/seeing-a-psychologist-on-medicare-soon-youll-be-back-to-10-sessions-but-we-know-thats-not-often-enough-194338">predictable criticism</a>, even though the program was <a href="https://insightplus.mja.com.au/2023/3/governments-better-access-initiative-must-change-to-prevent-a-mental-health-crisis/">demonstrably inequitable</a>. The government has recognised this gap, titling its mental health budget announcement “<a href="https://www.health.gov.au/resources/publications/laying-the-groundwork-for-mental-health-and-suicide-prevention-system-reform-budget-2023-24?language=en">laying the groundwork</a>”. </p>
<p>Overall, the health component of the 2023-2024 budget is well crafted. It signals a new priority for primary care and provides a new foundation for funding reform for the future. </p>
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Read more:
<a href="https://theconversation.com/seeing-a-psychologist-on-medicare-soon-youll-be-back-to-10-sessions-but-we-know-thats-not-often-enough-194338">Seeing a psychologist on Medicare? Soon you'll be back to 10 sessions. But we know that's not often enough</a>
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<p class="fine-print"><em><span>Stephen Duckett is Chair of the Board of Directors of Eastern Melbourne Primary Health Network and was a member of the Strengthening Medicare Taskforce </span></em></p>The big news on budget night was a tripling of the bulk-billing incentive. It’s hoped to stem the decline in bulk billing – but it’s unclear if it will increase it.Stephen Duckett, Honorary Enterprise Professor, School of Population and Global Health, and Department of General Practice, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2048002023-05-02T10:58:54Z2023-05-02T10:58:54ZNew Medicare reforms won’t fix everything but they start to tackle the system’s biggest problems<figure><img src="https://images.theconversation.com/files/523712/original/file-20230502-28-w6y3xw.jpg?ixlib=rb-1.1.0&rect=40%2C200%2C3190%2C1940&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://photos.aap.com.au/">AAP/Tracey Nearmy</a></span></figcaption></figure><p>Federal Health Minister Mark Butler has long said Medicare is in the <a href="https://www.sbs.com.au/news/article/australias-gp-system-in-the-worst-shape-in-40-years-mark-butler-warns/iquhpkxx5">worst shape</a> it’s been in decades. Premiers have come to successive national cabinet meetings saying primary care is failing – and demanding reform and investment.</p>
<p>Fortunately, the policies Minister Butler <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-care-speech-national-press-club-2-may-2023">outlined</a> today at the <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-care-speech-national-press-club-2-may-2023">National Press Club</a> to strengthen Medicare live up to challenge. These reforms will be funded with a total of A$2.2 billion</p>
<p>They certainly won’t fix everything. But instead of kicking the can down the road, or just addressing superficial symptoms, they start to tackle some of the biggest challenges in general practice: outmoded technology, GPs working with little support, a broken funding model, and restrictive regulations. </p>
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Read more:
<a href="https://theconversation.com/health-and-housing-measures-announced-ahead-of-budget-and-ndis-costs-in-first-ministers-sights-204675">Health and housing measures announced ahead of budget, and NDIS costs in first ministers' sights</a>
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<h2>Diagnosing the problem</h2>
<p>There are many visible and urgent crises in health care, ranging from falling rates of bulk-billing to overwhelmed hospital emergency departments. But the minister zeroed in on the one big structural failure driving many of these problems: Medicare hasn’t kept up with the health needs of Australians. </p>
<p>Medicare was established in the 1980s. Today, Australians are living longer, often with chronic diseases. Chronic diseases – such as heart disease, diabetes, asthma, and depression – are the leading cause of illness and death. <a href="https://www.aihw.gov.au/reports/australias-health/chronic-conditions-and-multimorbidity">Almost half</a> of Australians have one chronic condition; more than half of Australians over 65 have two or more. </p>
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<img alt="Doctor takes her patient's blood pressure" src="https://images.theconversation.com/files/523717/original/file-20230502-20-lx98hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523717/original/file-20230502-20-lx98hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523717/original/file-20230502-20-lx98hp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523717/original/file-20230502-20-lx98hp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523717/original/file-20230502-20-lx98hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523717/original/file-20230502-20-lx98hp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523717/original/file-20230502-20-lx98hp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Almost half of Australians have a chronic health condition.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/QTH2xmoJ_p0">Unsplash/CDC</a></span>
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<p>As Minister Butler noted, Medicare has not kept up and has “started to show its age”. A system designed for quick, one-off consultations with doctors isn’t a good fit for the more complex range of ongoing care and support many patients need today. </p>
<p>To update Medicare, the minister announced three areas of reform. </p>
<h2>1. Modernising digital systems</h2>
<p>With people likely to have multiple health conditions, and to see a range of professionals across the health system, it’s more important than ever for patients and clinicians to have relevant and up-to-date health information. That helps clinicians understand their patients’ needs. It also means patients don’t have to provide the same information again and again, or have duplicated, wasteful tests. </p>
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Read more:
<a href="https://theconversation.com/my-health-record-is-meant-to-empower-patients-but-with-little-useful-information-stored-is-it-worth-saving-199508">My Health Record is meant to empower patients – but with little useful information stored, is it worth saving?</a>
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<p>Australia’s digital systems are outdated, hard to use and ineffective. My Health record, our main digital health tool, is only used by <a href="https://journal.achsm.org.au/index.php/achsm/article/view/311/267">a small minority</a> of specialists, private hospitals and allied health providers. According to Minister Butler, only one in ten specialists use it, and only one in five radiology test results (such as X-rays or MRIs) are uploaded. </p>
<p>Computer systems in practices and hospitals usually can’t talk to each other, and often they aren’t connected to My Health Record.</p>
<p>To start to address this, more than $950 million will be spent on digital health, including keeping the Digital Health Agency running and improving My Health record.</p>
<h2>2. Building bigger teams</h2>
<p>To respond to the growing complexity of people’s health needs, most countries are moving towards “multidisciplinary” teams in general practice. Those teams might include nurses, physiotherapists, pharmacists, psychologies and administrative roles. This approach can improve care and take pressure off GPs. </p>
<p>As with digital systems, Australia is well behind other countries. Our GPs are <a href="https://grattan.edu.au/report/a-new-medicare-strengthening-general-practice/">more likely</a> to work on their own, or with little support. That’s because the way we fund general practice is stuck in the past, mostly restricted to paying GPs for disconnected, one-off consultations. </p>
<p>The <a href="https://www.health.gov.au/our-work/workforce-incentive-program/about">Workforce Incentive Program</a>, which funds general practices to hire a range of different health professionals, will be increased. For small clinics, and in areas with too little care to go around, <a href="https://www.health.gov.au/our-work/phn">Primary Health Networks</a> (regional bodies responsible for improving primary care) will fund and attract allied health professionals and nurses to work in GP clinics. </p>
<p>But the biggest change is a new way of funding care. Our outdated fee-for-service system rewards rushed consultations, is <a href="https://www.health.gov.au/sites/default/files/2023-04/independent-review-of-medicare-integrity-and-compliance_0.pdf">complex and confusing</a> for doctors, and blocks team-based care. For clinics and patients who choose to participate, a new system dubbed My Medicare will change that. </p>
<p>Patients will register with a preferred practice. The practice will then get a budget for treating them, on top of fees for each visit. Getting a patient-centred budget alongside visit fees will give care teams the flexibility to plan and deliver care in new and better ways. </p>
<p>Registering with a clinic will support strong relationships between patients and their care teams. Funding will be focused on that relationship, not on isolated visits, and will reflect the work of the whole care team, not just the GP. </p>
<h2>3. Unlocking workforce skills</h2>
<p>Along with measures to attract nurses to primary care settings, there will be a review of the barriers that stop health professionals using all their skills. </p>
<p>Australia has a thicket of inconsistent regulations and complex funding rules that result in double-handling, high costs, wasted talent and GPs having to do too much. The review is an opportunity to clear many of these barriers away, and make sure that workforce roles reflect the best evidence about how to provide safe, high-quality care.</p>
<p>Pharmacists will also <a href="https://www.health.gov.au/sites/default/files/2023-04/summary-of-strengthening-medicare-policies.pdf">do more</a>, with new funding for free vaccinations and expansions to treatment for people addicted to opioids. And there will be more training places in primary care for nurses, and efforts to attract nurses who have left the profession back into general practice. </p>
<hr>
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<strong>
Read more:
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<h2>Evolution not revolution – and a team effort</h2>
<p>The breadth of the proposals is important – there will be little progress without improvements in all those areas. </p>
<p>At the National Press Club, Minister Butler said “remaking Medicare for the 21st century will take persistent evolution, not overnight revolution”. </p>
<p>That incremental approach is important too, including making the most complex reform, My Medicare, voluntary. These changes will be hard, so participating clinicians and patients must be convinced of the benefits, willing to change, and ready for inevitable setbacks. </p>
<figure class="align-center ">
<img alt="Nurse shows a patient a pamphlet" src="https://images.theconversation.com/files/523719/original/file-20230502-18-1rui3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523719/original/file-20230502-18-1rui3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523719/original/file-20230502-18-1rui3z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523719/original/file-20230502-18-1rui3z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523719/original/file-20230502-18-1rui3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523719/original/file-20230502-18-1rui3z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523719/original/file-20230502-18-1rui3z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The Medicare reform process will be incremental.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/lNkRnZPfiwY">Unsplash/CDC</a></span>
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<p>The reforms won’t satisfy everyone, but this might be the biggest opportunity for primary care reform in a generation. </p>
<p>The minister remarked on the “pointy elbows and loud voices” of the various professional groups in health care that provided input through his <a href="https://www.health.gov.au/committees-and-groups/strengthening-medicare-taskforce#publications">Strengthening Medicare Taskforce</a>. This package needs the support of all the workforce groups involved in primary care, and a strong voice for patients. Hopefully they will work together to make sure these reforms succeed.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/heres-why-pharmacists-are-angry-at-script-changes-and-why-the-government-is-making-them-anyway-204028">Here's why pharmacists are angry at script changes – and why the government is making them anyway</a>
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<img src="https://counter.theconversation.com/content/204800/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Breadon's employer, Grattan Institute, has been supported in its work by government, corporates, and philanthropic gifts. A full list of supporting organisations is published at <a href="http://www.grattan.edu.au">www.grattan.edu.au</a>.</span></em></p><p class="fine-print"><em><span>Lachlan Fox's employer, Grattan Institute, has been supported in its work by government, corporates, and philanthropic gifts. A full list of supporting organisations is published at <a href="http://www.grattan.edu.au">www.grattan.edu.au</a>.</span></em></p>The new reforms tackle some of the biggest challenges in general practice: outmoded technology, GPs working with little support, a broken funding model and restrictive regulations.Peter Breadon, Program Director, Health and Aged Care, Grattan InstituteLachlan Fox, Associate, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2040292023-04-20T20:02:27Z2023-04-20T20:02:27ZIf you live in a bulk-billing ‘desert’ it’s hard to see a doctor for free. Here’s how to fix this<figure><img src="https://images.theconversation.com/files/521979/original/file-20230419-28-a9e1kl.jpg?ixlib=rb-1.1.0&rect=11%2C104%2C7764%2C5024&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-examining-sick-patient-face-mask-1718117674">Shutterstock</a></span></figcaption></figure><p>GP fees are hitting more Australians than they did a few years ago. There’s a lot of talk about a crisis in bulk billing, with many people reporting they’re unable to see a doctor without paying an out-of-pocket fee. </p>
<p>But the biggest, most urgent problem is in the communities where most people pay fees, so called bulk-billing “deserts”. These deserts are more likely in poorer areas, so the people who most need bulk billing are missing out.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1647859792986120193"}"></div></p>
<p>While Medicare funding changes are needed to address this problem, we also need to look at more innovative solutions. One option is for federal and state governments to <a href="https://grattan.edu.au/wp-content/uploads/2022/12/A-new-Medicare-strengthening-general-practice-Grattan-Report.pdf">step in</a> and support or set up clinics that employ doctors, nurses and other health workers. </p>
<h2>Bulk billing is falling, but from a historic high</h2>
<p>The share of patients who <a href="https://www.health.gov.au/resources/publications/medicare-statistics-per-patient-bulk-billing-dashboard-2021-22?language=en">never paid a GP fee fell</a> from 67% in 2020-21 to 64% in 2021-22. But those rates are still high by recent standards. The rate has only fallen back to the level of 2015, and it remains much higher than a decade ago.</p>
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<a href="https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521791/original/file-20230419-26-gvtlwq.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>Yes, it’s troubling to see bulk billing falling, especially when fees have risen a lot. Patients who are not bulk billed now pay <a href="https://www.health.gov.au/resources/publications/medicare-annual-statistics-state-and-territory-2009-10-to-2021-22?language=en">on average A$45</a> out of pocket when they see a GP. This is up 20% in real terms over the past decade. </p>
<p>But while the national trend is concerning, it masks a much bigger problem.</p>
<h2>Great disparity</h2>
<p>In some parts of Australia – for example, <a href="https://www.theguardian.com/news/datablog/2023/feb/17/revealed-the-areas-where-australians-are-struggling-to-access-free-gp-care">the electorates</a> of Chiefly, Fowler, and Werriwa in outer-western Sydney – more than nine in ten GP patients are always bulk billed. </p>
<p>But in other parts – for example, the electorates of Canberra, and Franklin and Clark in southern Tasmania – that figure is less than four in ten. </p>
<p>Unlike the overall bulk-billing rate, these vast disparities have persisted for many years: the problem was just as bad a decade ago. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521790/original/file-20230419-20-41cvqa.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p>Bulk-billing deserts wouldn’t be such a problem if they were only in the wealthiest parts of Australia, because fees are less likely to stop wealthy people getting the care they need. But there are bulk-billing deserts in many poorer areas. </p>
<p>Compared to all but the wealthiest areas, the bottom fifth of electorates by income have the lowest bulk-billing rates. In 13 of the lowest-income electorates, less than 60% of patients are bulk billed. </p>
<p>Rural areas are worse off too: 60% of patients in rural areas are always bulked billed, compared to almost 69% in metropolitan areas.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521792/original/file-20230419-241-gvtlwq.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p>The bulk-billing deserts in poorer parts of Australia represent a serious failure of the system. Nationally, about <a href="https://www.abs.gov.au/statistics/health/health-services/patient-experiences/latest-release">3.5%</a> of people say they skip GP care because of the cost, with higher rates in rural and poorer areas. Those figures will be far higher in bulk-billing deserts, putting many people’s health at risk. </p>
<h2>What the government should do</h2>
<p>There have been <a href="https://www1.racgp.org.au/newsgp/professional/crisis-summit-white-paper-released">calls</a> to pour billions of dollars into increasing the Medicare rebate and bulk billing incentives. </p>
<p>But while the government should make sure payments to GPs keep up with their costs, that won’t fix the problem of bulk-billing deserts. </p>
<p>It might help arrest the decline in bulk billing nationally, and in some areas where bulk billing is low. But the money will mostly flow to high-bulk billing areas – it won’t do much to provide more care where there is far too little. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/general-practices-are-struggling-here-are-5-lessons-from-overseas-to-reform-the-funding-system-188902">General practices are struggling. Here are 5 lessons from overseas to reform the funding system</a>
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<p>Bulk billing deserts are an enduring problem that need new solutions. To turn them around, the government must tackle two of the structural problems causing them: one-size-fits-all funding of GPs, and areas that don’t have enough health care to go around. </p>
<p>The government has already <a href="https://www.health.gov.au/sites/default/files/2023-02/strengthening-medicare-taskforce-report_0.pdf">signalled</a> it will develop a new funding model that pays GPs for providing ongoing care, which would improve on the current <a href="https://www.health.gov.au/resources/publications/independent-review-of-medicare-integrity-and-compliance?language=en">outdated and dysfunctional system</a>. That funding should give <a href="https://theconversation.com/general-practices-are-struggling-here-are-5-lessons-from-overseas-to-reform-the-funding-system-188902">higher payments</a> for patients with greater need. </p>
<p>That would boost income for clinics with patients who need free care the most, helping those clinics to avoid charging their patients. It would be a big step in the right direction.</p>
<figure class="align-center ">
<img alt="Clinician checks a patient's blood pressure" src="https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521980/original/file-20230420-2867-5s2pdd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Funding reform will help clinics avoid overcharging patients.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/male-nurse-measures-blood-pressure-senior-1817431535">Shutterstock</a></span>
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<p>But even then, there would still be areas without enough health-care workers to meet the community’s needs, including many rural areas, resulting in too little care, and <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/joie.12098">too little bulk billing</a>. Governments must go well beyond the Medicare rebate and other incentives to fix these broken health-care “markets”. </p>
<p>The federal and state governments need to <a href="https://grattan.edu.au/wp-content/uploads/2022/12/A-new-Medicare-strengthening-general-practice-Grattan-Report.pdf">step in</a> to support existing clinics or set up new ones that employ salaried health-care workers. This support needs to be tailored to local needs. It could be employing a GP to work out of a rural hospital if there are no GPs in the area, or setting up a new <a href="https://treasury.gov.au/sites/default/files/2022-03/258735_national_rural_health_alliance.pdf">community-controlled primary care service</a>, or helping an existing clinic hire extra staff. </p>
<p>Rather than ad hoc announcements, there should be secure national funding for this care, targeted at the areas of greatest need – especially the poorest bulk-billing deserts. </p>
<p>This change should be accompanied by many other reforms to attract clinicians to areas where they’re needed most, such as further expanding new <a href="https://www.abc.net.au/news/2023-04-15/gp-s-idea-for-rural-generalist-hub-to-avoid-doctor-burnout/102102204">models</a> of GP <a href="https://www.mlhd.health.nsw.gov.au/getmedia/0d396ca5-0028-4cca-99ac-e573dd90bda8/A4-Brochure-Rural-Generalist-Training-Pathway">employment</a> and <a href="https://www.abc.net.au/news/2023-01-27/australia-first-trial-to-retain-gps-in-rural-areas/101898362">training</a> in rural areas, which give “<a href="https://www.health.gov.au/our-work/national-rural-generalist-pathway">rural generalist</a>” doctors a single employer during their training across a range of different health settings in a region.</p>
<p>There should also be reforms to expand the teams supporting GPs in areas with too little care. This can reduce GP burnout, allow clinics to provide more care, and bring Australia <a href="https://grattan.edu.au/wp-content/uploads/2022/12/A-new-Medicare-strengthening-general-practice-Grattan-Report.pdf">in line</a> with other countries. As well as administrative, allied health, pharmacist and other roles, some teams could include <a href="https://grattan.edu.au/wp-content/uploads/2014/04/196-Access-All-Areas.pdf">physician assistants</a>, who work under the supervision of a doctor and can provide the full range of services a doctor provides.</p>
<p>One test for next month’s federal budget is whether it funds solutions to bulk-billing deserts – an enduring injustice in our health-care system.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/medicare-reform-is-off-to-a-promising-start-now-comes-the-hard-part-197914">Medicare reform is off to a promising start. Now comes the hard part</a>
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<img src="https://counter.theconversation.com/content/204029/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Breadon's employer, Grattan Institute, has been supported in its work by government, corporates, and philanthropic gifts. A full list of supporting organisations is published at <a href="http://www.grattan.edu.au">www.grattan.edu.au</a>.</span></em></p><p class="fine-print"><em><span>Lachlan Fox's employer, Grattan Institute, has been supported in its work by government, corporates, and philanthropic gifts. A full list of supporting organisations is published at <a href="http://www.grattan.edu.au">www.grattan.edu.au</a>.</span></em></p>In Australia’s bulk-billing ‘deserts’, it’s incredibly difficult to find a doctor who will bulk bill. The government should step in to support or set up clinics so locals have access to health care.Peter Breadon, Program Director, Health and Aged Care, Grattan InstituteLachlan Fox, Associate, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2035612023-04-18T20:01:47Z2023-04-18T20:01:47ZMedicare billing is a problem but our research found many more GPs undercharge<figure><img src="https://images.theconversation.com/files/520646/original/file-20230413-18-4oyane.jpg?ixlib=rb-1.1.0&rect=68%2C53%2C5002%2C3327&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-consultant-meeting-teenage-patient-284516786">Shutterstock</a></span></figcaption></figure><p>Australia’s Medicare billing system is overly complicated, bureaucratic and not meeting the needs of a modern health service, potentially leaking billions of dollars. But claims this loss is mostly due to fraudulent billing practices by GPs are inaccurate. </p>
<p>In October, the ABC’s 7.30 program and the Nine newspapers <a href="https://www.smh.com.au/politics/federal/medicare-is-haemorrhaging-the-rorts-and-waste-costing-taxpayers-billions-of-dollars-a-year-20221013-p5bpp9.html">raised concerns</a> about an estimated A$8 billion in Medicare waste, caused by a mixture of doctors’ errors, over-servicing and outright fraud. The examples given, however, were almost exclusively intentional fraud, mainly in general practice. This promoted health minister Mark Butler to commission an <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/independent-review-into-medicare-compliance">independent review</a>, led by Dr Pradeep Philip.</p>
<p>The <a href="https://www.health.gov.au/resources/publications/independent-review-of-medicare-integrity-and-compliance?language=en">Philip review</a>, released earlier this month, was highly critical of the current Medicare system and found non-compliance and fraud accounted for $1.5 to $3 billion of Medicare waste.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1643122020585029632"}"></div></p>
<p>Our research team <a href="https://www1.racgp.org.au/ajgp/2023/april/general-practitioner-charging-of-medicare">analysed GP activity</a> recorded during almost 90,000 patient encounters to assess how GPs were billing for the services they provided. </p>
<p>We found GPs undercharged at 11.8% of encounters and overcharged at 1.6%. This suggests GPs aren’t routinely defrauding Medicare, and in fact have saved the system equivalent to $351 million in the 2021-22 financial year. </p>
<p>However, we agree the current billing system needs to be urgently reformed.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/general-practices-are-struggling-here-are-5-lessons-from-overseas-to-reform-the-funding-system-188902">General practices are struggling. Here are 5 lessons from overseas to reform the funding system</a>
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</em>
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<h2>How does Medicare billing work?</h2>
<p>GPs claim a fee for service, called a rebate, which is a fixed amount ascribed on the Medicare Benefits Schedule (MBS), based on the type of service provided. </p>
<p>There are nearly 6,000 MBS item numbers. GPs can charge for one or more MBS items for a patient service. </p>
<p>Around 90% of MBS items claimed by GPs are considered standard consultation items (surgery, residential aged care facility visits, home visits and so on), that are in four levels (A, B, C and D) which increase in length. </p>
<p>The cost associated increases with each level. An example of an error would be a GP accidentally charging for a Level C consultation (requires 20 minutes or longer; $76.95 rebate) when the visit only met the criteria for a Level B (less than 20 minutes; rebate of $39.75). An example of under-billing is when a GP is entitled to claim for a Level C but charges only a Level B. </p>
<p>An example of over-servicing is a pathology test for blood glucose level being repeated for the same patient at consecutive visits, where the patient’s condition did not warrant the second test. </p>
<p>An example of fraud would be claiming for a service that had not been provided.</p>
<figure class="align-center ">
<img alt="patients wait in a GP clinic waiting room" src="https://images.theconversation.com/files/521169/original/file-20230417-16-dpm1yh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521169/original/file-20230417-16-dpm1yh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521169/original/file-20230417-16-dpm1yh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521169/original/file-20230417-16-dpm1yh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521169/original/file-20230417-16-dpm1yh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521169/original/file-20230417-16-dpm1yh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521169/original/file-20230417-16-dpm1yh.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">Rebates are based on the time spent with the patient.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woodbridge-suffolk-6-july-2021-people-2003258147">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Examining doctors’ billing in the real world</h2>
<p>The data we analysed in our peer-reviewed <a href="https://www1.racgp.org.au/ajgp/2023/april/general-practitioner-charging-of-medicare">study</a> were collected between 2013-2016 from nationally representative samples of GPs during 89,765 real-time encounters with their patients. The GPs recorded the start and finish time for each visit. </p>
<p>The Philip review did not try to quantify the amount of underbilling. </p>
<p>We decided to examine the billing data following the 7.30 Report/Nine news investigation, but the participants could not have been influenced by these reports as the data we used were collected prior to the ABC/Nine publications.</p>
<h2>Why would doctors undercharge?</h2>
<p>We theorised GPs were likely undercharging Medicare for two reasons:</p>
<p>1) while time is the predominant measure, GPs are likely to still consider content and complexity when billing standard Medicare items, rather than just billing according to the time spent with the patient</p>
<p>2) fear of triggering a professional services review (PSR) of their billing.</p>
<p>A professional services review can be triggered for a variety of reasons, for example, a GP has a higher proportion of longer consultations than might be expected. A professional services review involves an audit of the GP’s billing. It can potentially lead to a decision that can prevent the GP from being able to bill Medicare.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/6-reasons-why-its-so-hard-to-see-a-gp-199284">6 reasons why it's so hard to see a GP</a>
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</em>
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<hr>
<p>Last week, <a href="https://www.healthed.com.au/">HealthED</a>, a health education company, included three post-webinar questions on this topic in an online survey of 1,852 GPs from across Australia. Answering these questions was not compulsory.</p>
<p>The results showed most (83.3%) GPs consider the length and complexity of the consultation when billing Level C and D items, even though increased complexity is no longer required (since 2011).</p>
<p>More than half (60.3%) intentionally under-billed Medicare in the previous week. </p>
<p>The most common reasons for under-billing were:</p>
<ul>
<li><p>they did not feel that the content of the consultation justified a higher MBS item (41.9%)</p></li>
<li><p>fear of triggering a professional services review alert (33.5%)</p></li>
<li><p>confusion around Medicare schedule criteria (30.8%).</p></li>
</ul>
<p>These responses correlate with the findings from our nationally representative sample, which suggests GPs predominantly act with integrity, but also based on fear and confusion.</p>
<h2>Time to reform Medicare billing</h2>
<p>A simplification of the current very complex Medicare billing system would resolve a lot of waste through unintended errors. Reducing low value and unnecessary care is not a simple task as these are difficult to define, and often rely on situational judgement. When systems are no longer fit for purpose, they should be reviewed and revised, as the Philip review has recommended.</p>
<p>There are bad actors in every profession and those who “game” Medicare should be called out. However, the claims of widespread fraud have not been supported by our work or the Philip review.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/with-so-many-gps-leaving-the-profession-how-can-i-find-a-new-one-190666">With so many GPs leaving the profession, how can I find a new one?</a>
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<img src="https://counter.theconversation.com/content/203561/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>New research suggests GPs aren’t routinely defrauding Medicare, and in fact have saved the system hundreds of millions of dollars by under-billing.Christopher Harrison, Senior Lecturer, Sydney School of Public Health, University of SydneyJoan Henderson, Senior Research Fellow (Hon), University of Sydney. Editor, Health Information Management Journal (HIMJ), University of SydneyMelissa Kang, Associate Professor, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2032222023-04-16T12:19:13Z2023-04-16T12:19:13ZAn emergency in the making: Ending pandemic prenatal health coverage for uninsured people is both costly and dangerous<figure><img src="https://images.theconversation.com/files/521097/original/file-20230414-28-nn18d8.jpg?ixlib=rb-1.1.0&rect=39%2C45%2C3675%2C2369&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Research shows that uninsured people are more likely to get care later in pregnancy, and less care overall. This increases risks for mothers and babies.
</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/an-emergency-in-the-making--ending-pandemic-prenatal-health-coverage-for-uninsured-people-is-both-costly-and-dangerous" width="100%" height="400"></iframe>
<p>On March 31, 2023 the Ford government in Ontario <a href="https://health.gov.on.ca/en/pro/programs/ohip/bulletins/redux/bul230305.aspx">ended the expanded health-care funding</a> it put in place when the COVID-19 pandemic began in March 2020. </p>
<p>This funding allowed everyone in Ontario to access essential health care. For the <a href="https://www.hnuc.org/reports">hundreds of thousands of people living in the province without health insurance</a>, this meant access to necessary surgeries, emergency care and labour and delivery services without thousands of dollars in <a href="https://www.qch.on.ca/WithoutInsuranceChildbirthFees">hospital and physician bills</a>.</p>
<p>As a midwife who has worked in Toronto for over 20 years, largely with uninsured populations, and an associate professor who has focused my research and activism on this issue, I am acutely aware of how these cuts will impact pregnant people and ultimately all Canadians.</p>
<h2>Insurance status</h2>
<p>There are many reasons someone <a href="https://doi.org/10.29173/alr778">may not have health insurance</a>. These can include homelessness; mental health issues; addiction; <a href="https://static1.squarespace.com/static/63aeec46560bfa003a5030f6/t/63c49984c13ada20b0eb222f/1673828740700/famvio.pdf">having documents withheld by an abusive partner</a>, <a href="https://doi.org/10.1007/s10903-021-01273-w">landlord or employer</a>; and, for a growing number of people who live and work across Canada, <a href="http://dx.doi.org/10.1080/13621020902850643">lack of legal immigration status</a>. </p>
<p>Increasingly, people may spend years with precarious immigration status, all the while building a life here and eagerly waiting for applications to come through. For example, <a href="https://www.cic.gc.ca/english/helpcentre/answer.asp?qnum=492&top=15">a student applying for a work permit</a> may fall out of status while one application expires and another comes through. </p>
<p>Research shows that uninsured people are more likely to <a href="https://doi.org/10.1016/j.jogc.2018.10.008">get care later in pregnancy and less care overall</a>. It is well accepted across medicine that <a href="https://www.canada.ca/en/public-health/services/publications/healthy-living/maternity-newborn-care-guidelines-chapter-3.html">prenatal care is linked to healthier outcomes</a> for <a href="https://www.americanprogress.org/article/ensuring-healthy-births-prenatal-support/">pregnant people and babies</a>. In particular, prenatal care is associated with <a href="https://doi.org/10.1016/j.ajog.2010.03.001">dramatically lower rates of preterm birth</a> and low birth weight babies.</p>
<p>Health-care costs for babies born too small and too early are among the highest of all health-care expenditures. It’s estimated that <a href="https://doi.org/10.9778%2Fcmajo.20170128">Canada spends about $8 billion per year in health costs related to preterm babies</a>. Babies born too small and too early are also among the most likely to have lifelong health issues, including profound cognitive and physical impairment. </p>
<p>There is a simple bottom line argument here: prenatal care is cheap and sick babies are very expensive.</p>
<h2>Refugees in all but name</h2>
<p>With <a href="https://www.cbc.ca/news/politics/roxham-road-global-migration-analysis-wherry-1.6759766">increasing global health and economic disparities</a>, we are seeing more people cross and/or stay within our borders to work and live. Like many others who work with these populations, I can say that many who do not have refugee status are refugees in all but name: <a href="https://theconversation.com/refugee-stories-reveal-anxieties-about-the-canada-u-s-border-127394">escaping impossible conditions</a> and trying to build a future here. </p>
<p>The same week the Ontario government discontinued its expanded health-care coverage, <a href="https://www.thestar.com/news/canada/2023/03/31/authorities-in-akwesasne-hunt-for-missing-child-after-six-bodies-found-in-quebec-marsh.html">eight people drowned trying to cross the St. Lawrence River</a> in Québec while trying to escape deportation. These are the acts of desperate people. </p>
<p>While hospitals are not going to turn people away in emergencies, many pregnant people need access to hospital-based care before there is an emergency, and in fact to avoid an emergency. For example, someone who needs a caesarean section because labour would be too risky, may be <a href="https://toronto.ctvnews.ca/uninsured-patients-denied-scheduled-c-sections-unless-they-pay-6-000-midwife-says-1.6338249">required to pay $6,000</a> or <a href="https://www.qch.on.ca/WithoutInsuranceChildbirthFees">even more</a> before they can access a provider. </p>
<p>For some people, this could mean deciding between rent, feeding their children or getting basic health care.</p>
<h2>Inevitable emergencies</h2>
<p>It is inevitable that many people will not have access to prenatal care and will wind up in an emergency department, where the hospital will be <a href="https://www.health.gov.on.ca/en/pro/programs/ohip/bulletins/redux/bul230305.aspx">ethically required to provide care anyway</a>. Hospitals requiring advance payment does not make people less pregnant, less high-risk or less in need of a caesarean. It means people going without care and coming to the hospital in need of emergency surgery, which has the <a href="https://secure.cihi.ca/free_products/Costs_Report_06_Eng.pdf">highest cost</a> and <a href="https://doi.org/10.33314/jnhrc.v18i2.2093">risks of any birth</a>. </p>
<p>Adding another layer of complexity to this puzzle is that, as <a href="http://dx.doi.org/10.1136/bmjgh-2021-005671">global caesarean section rates skyrocket</a>, more and more undocumented migrants in Canada have had a previous caesarean section. For many, this means the safest option for delivery is a <a href="https://doi.org/10.1503/cmaj.170371">repeat caesarean section</a>.</p>
<p>Putting all the pieces together, discontinuing expanded health-care funding means higher numbers of already marginalized people having less prenatal care, more preterm births and low birth weight babies, and more emergency caesarean sections for delivery — all of which result in worse outcomes, more cost on the system and more moral distress on health care providers. How is this a good idea from any angle?</p>
<p><a href="https://static1.squarespace.com/static/63aeec46560bfa003a5030f6/t/64179ae782bfa26c01352025/1679268584210/A+Bridge+to+Universal+Healthcare.pdf">A study released just one week before these cuts were announced</a> showed the many benefits of having the expanded funding in place, including improved access to prenatal care. It also demonstrated the relief health-care providers felt at not having the moral distress of having to decide who was able to access necessary care. </p>
<h2>Lessons learned</h2>
<p>The expanded funding put in place during COVID-19 revealed a few things. </p>
<p>First, the fact that it was implemented is an acknowledgement that it was needed. If we have universal health coverage for all who live here, why did we need the program in the first place? </p>
<p>Second, it demonstrated that it was not a massive burden to our health-care system to provide this care. The Ontario Medical Association estimated this program cost <a href="https://ottawacitizen.com/news/local-news/provinces-move-to-cut-payment-for-people-without-health-cards-concerns-doctors-association-head">$15 million over three years</a>. Even if it was several times more, this is very little of our <a href="https://budget.ontario.ca/2022/fallstatement/chapter-3.html">health-care budget</a>. By providing primary and preventive care, as well as prenatal care, the program likely saved money by <a href="https://static1.squarespace.com/static/63aeec46560bfa003a5030f6/t/64179ae782bfa26c01352025/1679268584210/A+Bridge+to+Universal+Healthcare.pdf">avoiding more expensive acute and emergency care</a>, and it certainly saved lives.</p>
<p>Third, this program brought <a href="https://www.ontariomidwives.ca/sites/default/files/Policy%20positions%20and%20submissions/Non-insured-collective-Statement-Final-with-logos%20330%20pm%20March%2029%202023.pdf">caregivers and organizations together</a>, with health-care associations asserting that this is a <a href="https://static1.squarespace.com/static/63aeec46560bfa003a5030f6/t/63c48fcd5edaa632a269ea1e/1673826253563/Equitable-Access-to-OHIP-Registration-for-Newborns-.pdf">health equity issue, not a medical tourism issue</a>. Immigration status has long been established as a <a href="https://doi.org/10.1007/s10903-021-01273-w">social determinant of health</a>, along with factors including poverty, racialization and education level. It is about time we address this issue in Canada.</p>
<p>The decision to discontinue extended care is going to cost us. Not just in terms of health-care dollars — it is always better to treat high blood pressure than manage a stroke — but in terms of our ethics. </p>
<p>Several decades ago, we decided as a country that everyone — rich or poor — deserves access to health care. <a href="https://www150.statcan.gc.ca/n1/daily-quotidien/210928/dq210928c-eng.htm">Canadians have taken pride</a> in this and it is part of our national identity. Until everyone is covered, we need to acknowledge that we do not, in fact, have universal health care, and decide what this means to us as a country. </p>
<p><em>This article was co-authored by Shezeen Suleman of Toronto Metropolitan University, and Rachel Spitzer, AJ Mata and Jenny Yang Klimis of University of Toronto.</em></p><img src="https://counter.theconversation.com/content/203222/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Manavi Handa 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>Discontinuing expanded health-care funding will result in less prenatal care for uninsured patients, more health risks, higher costs to the health system, and moral distress for health-care providers.Manavi Handa, Associate Professor, Midwifery Education Program, Toronto Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2035432023-04-11T06:16:00Z2023-04-11T06:16:00ZWhat if Medicare was restricted to GPs who bulk billed? This kind of reform is possible<p>Australia’s health system is under significant pressure. The Labor government has inherited a system with declining bulk-billing rates for GP visits. These fell from almost 90% of all GP attendances bulk billed in December 2021 to <a href="https://www.health.gov.au/resources/collections/medicare-statistics-collection?language=en">just over 80% a year later</a>.</p>
<p>Significant workforce shortages remain in rural and remote Australia, despite a raft of incentive programs to improve access to health care. In 2021–22, about <a href="https://www.abs.gov.au/statistics/health/health-services/patient-experiences/latest-release#barriers-to-health-service-use">3.5% of adults did not see a GP because of cost</a>, with higher rates of missed care outside metropolitan areas.</p>
<p>Policymakers may have relied on ineffectual financial incentives because they thought they were precluded from stronger actions, such as limiting doctors’ access to rebates in areas of oversupply. However, as we argue in the <a href="https://journals.sagepub.com/doi/10.1177/0067205X231165872">Federal Law Review</a>, these constraints have been overstated.</p>
<p>This means it would be possible to radically alter the Medicare system. One option is to restrict Medicare access to GPs who agree to bulk bill all patients, while allowing those who don’t bulk bill to rely solely on out-of-pocket payments. </p>
<p>A new Medicare agenda should address the problems of fraud, geographical inequity, and bulk-billing decline. This can be done by conceptualising access to Medicare rebates by practitioners as a privilege, not a right. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/gps-are-abandoning-bulk-billing-what-does-this-mean-for-affordable-family-medical-care-182666">GPs are abandoning bulk billing. What does this mean for affordable family medical care?</a>
</strong>
</em>
</p>
<hr>
<h2>Why were policymakers constrained?</h2>
<p>Health policy in Australia has been limited for decades by assumed constitutional constraints, which have been <a href="https://www.tandfonline.com/doi/abs/10.1080/14662048008447356?journalCode=fccp19">talked up</a> by the medical profession to prevent policies they oppose. </p>
<p>After the second world war, the Chifley Labor government began a series of social security reforms. Legislation for one element of the reform – a pharmaceutical benefits scheme – was <a>struck down by the High Court</a> because there was no relevant head of power in the Constitution. </p>
<p>In response, the government proposed amending the Constitution to give it broad social welfare powers. This proposal had bipartisan support and was passed at a referendum in 1946. A new sub-section (xxiiiA) was consequently added to section 51 of the Constitution, giving the Commonwealth power to make laws about:</p>
<blockquote>
<p>The provision of maternity allowances, widows’ pensions, child endowment, unemployment, pharmaceutical, sickness and hospital benefits, medical and dental services (but not so as to authorise any form of civil conscription), benefits to students and family allowances.</p>
</blockquote>
<p>The parenthetical civil conscription constraint was included following an amendment from the Liberal Party. This was motivated by a desire to prevent the creation of a scheme like the United Kingdom’s National Health Service, which required all GPs to work under contract to government and hospital specialists to be salaried employees. </p>
<p>The presumed constitutional constraint seemed to shape the Labor Party’s thinking about what might be constitutionally possible when designing Medibank, the precursor to Medicare. Despite some members of caucus supporting a salaried hospital system, this was not pursued.</p>
<figure class="align-center ">
<img alt="Masked man sits in medical waiting room" src="https://images.theconversation.com/files/520167/original/file-20230411-24-thnam3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/520167/original/file-20230411-24-thnam3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/520167/original/file-20230411-24-thnam3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/520167/original/file-20230411-24-thnam3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/520167/original/file-20230411-24-thnam3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/520167/original/file-20230411-24-thnam3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/520167/original/file-20230411-24-thnam3.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">Current workforce incentives aren’t addressing the gaps.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mature-man-face-mask-sitting-bright-1780828457">Shutterstock</a></span>
</figcaption>
</figure>
<p>But in <a href="https://staging.hcourt.gov.au/assets/publications/judgments/1980/031--GENERAL_PRACTITIONERS_SOCIETY_v._THE_COMMONWEALTH--(1980)_145_CLR_532.html">1980</a> and <a href="https://www.austlii.edu.au/cgi-bin/viewdoc/au/cases/cth/HCA/2009/3.html?context=1;query=selim;mask_path=au/cases/cth/HCA">2009</a>, the High Court narrowed the meaning of civil conscription. This meant the subsection no longer constrained government power in the way it once had.</p>
<p>Medical practitioners now work in a diverse range of settings, not all of which rely fully on revenue from Medicare. So the nexus between access to Medicare rebates and the ability to work as a doctor has been broken. The government can now expand the constraints it puts on billing rights without it being considered civil conscription.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/labor-has-a-huge-health-agenda-ahead-of-it-what-policies-should-we-expect-182764">Labor has a huge health agenda ahead of it. What policies should we expect?</a>
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</em>
</p>
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<h2>A bold way to restructure Medicare</h2>
<p>It is time for a complete rethink of how Medicare payment arrangements are designed and regulated, free from the assumed constitutional constraints. </p>
<p>The recent <a href="https://www.health.gov.au/resources/publications/independent-review-of-medicare-integrity-and-compliance?language=en">Independent Review of Medicare Integrity and Compliance</a> highlighted that:</p>
<blockquote>
<p>the current state of Medicare, and some of the challenges […] are the result of previous attempts to apply discrete and band-aid solutions to single issues over time and a lack of system thinking and consideration.</p>
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<p>The band-aid approach no longer works. A fundamental rethink of Medicare is required, moving away from practitioners’ relatively unconstrained and uncapped access to fee-for-service rebates.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/6-reasons-why-its-so-hard-to-see-a-gp-199284">6 reasons why it's so hard to see a GP</a>
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</em>
</p>
<hr>
<p>Presently, all specialists – including GPs – can apply for a Medicare provider number which enables rebate payments for their services, with few constraints. </p>
<p>Rather than an “all comers” approach, a new basis for Medicare could be one where practices sign up to Medicare and agree to meet Medicare’s contractual conditions such as agreement to bulk bill all patients, participation in training future health professionals and in quality improvement programs, and that practices are multidisciplinary. Again, fair remuneration needs to underpin all this. </p>
<p>Participating practices could be paid on a variety of bases, including number and type of patients enrolled, number of patient attendances (enrolled or not), and other payments. </p>
<p>Payment rates would need to be seen as fair by both government and practices.</p>
<figure class="align-center ">
<img alt="Doctors' arms crossed" src="https://images.theconversation.com/files/520168/original/file-20230411-18-zfr949.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/520168/original/file-20230411-18-zfr949.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/520168/original/file-20230411-18-zfr949.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/520168/original/file-20230411-18-zfr949.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/520168/original/file-20230411-18-zfr949.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/520168/original/file-20230411-18-zfr949.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/520168/original/file-20230411-18-zfr949.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">Currently, all specialists can apply for a Medicare provider number.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/crop-unrecognizable-male-doctor-with-stethoscope-4021775/">Pexels/Karolina Grabowska</a></span>
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</figure>
<p>A participation basis for Medicare, moving away from an unconstrained approach, coupled with adequate workforce planning, could also be used to encourage new graduates to work in locations and specialties in short supply by limiting access to rebates for specialties in locations of oversupply. </p>
<p>This would also facilitate management of fraud and over servicing through contractual controls, rather than cumbersome administrative law processes.</p>
<p>A “participating provider” approach would transform the patient experience. Most importantly, the bulk-billing lottery would end: practices displaying a Medicare sign would bulk bill all patients, not just some. </p>
<p>There would need to be a new deal for doctors too, with remuneration set fairly – not at the whim of government – ending the political <a href="https://theconversation.com/what-is-the-medicare-rebate-freeze-and-what-does-it-mean-for-you-114169">fee freezes suffered under the previous government</a>.</p>
<h2>Australia’s Medicare fabric has many holes</h2>
<p>Although Medicare has served Australia well, it’s beginning to fray at the edges with reductions in bulk billing and provider satisfaction, and geographical shortages. </p>
<p>The old incentive structures have not addressed these problems and now new approaches, which may previously have been thought impossible in part because of the perceived constitutional constraints, must be considered.</p>
<p>What we have is shown is that the policy agenda is more open than might have hitherto been considered. The time is right for these options to be considered.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-do-you-fix-general-practice-more-gps-wont-be-enough-heres-what-to-do-195447">How do you fix general practice? More GPs won't be enough. Here's what to do</a>
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<p><em>This article was co-authored by Emma Campbell, former Grattan Institute intern and current LLB/BPPE student at The Australian National University.</em></p><img src="https://counter.theconversation.com/content/203543/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Duckett was a member of the Strengthening Medicare Task Force.</span></em></p><p class="fine-print"><em><span>Fiona McDonald receives funding from the Medical Research Council (UK). </span></em></p>Medicare access could be restricted to GPs who agree to bulk bill all patients, while allowing those who don’t bulk bill to rely solely on out-of-pocket payments.Stephen Duckett, Honorary Enterprise Professor, School of Population and Global Health, and Department of General Practice, The University of MelbourneFiona McDonald, Associate Professor at the Australian Centre for Health Law Research, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2013602023-03-16T12:37:05Z2023-03-16T12:37:05ZWhy it’s hard for the US to cut or even control Medicare spending<figure><img src="https://images.theconversation.com/files/515188/original/file-20230314-3582-48y9sf.jpg?ixlib=rb-1.1.0&rect=77%2C94%2C5673%2C2862&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The number of Americans covered by Medicare is growing.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/female-friends-walking-with-nordic-walking-poles-in-royalty-free-image/1339068107">OR Images/DigitalVision via Getty Images</a></span></figcaption></figure><p>President Joe Biden’s 2024 proposed budget includes plans to <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2023/03/07/fact-sheet-the-presidents-budget-extending-medicare-solvency-by-25-years-or-more-strengthening-medicare-and-lowering-health-care-costs/">shore up the finances of Medicare</a>, the <a href="https://www.cms.gov/Medicare/Medicare-General-Information/MedicareGenInfo">federal health insurance program</a> that covers Americans who are 65 and up and some younger people with disabilities.</p>
<p>His administration aims to increase <a href="https://crsreports.congress.gov/product/pdf/IF/IF11820">from 3.8% to 5%</a> an existing Medicare tax that’s collected on the labor and investment earnings of <a href="https://www.cnbc.com/2023/03/08/what-to-know-about-proposed-biden-tax-on-the-wealthy-to-fund-medicare.html">Americans who make more than US$400,000 annually</a>. It also aims to reap some savings from having the government <a href="https://www.politico.com/newsletters/politico-pulse/2023/03/10/the-white-houses-health-care-wish-list-00086344">negotiate prices on more prescription drugs</a>.</p>
<p>The White House projects that these changes would generate an additional <a href="https://www.whitehouse.gov/wp-content/uploads/2023/03/budget_fy2024.pdf">$650 billion</a> in revenue over a decade. <a href="https://budgetmodel.wharton.upenn.edu/issues/2023/3/10/president-bidens-proposal-to-extend-medicare-trust-fund">Some independent experts</a> concur.</p>
<p><a href="https://scholar.google.com/citations?hl=en&user=CwMgD5QAAAAJ">As economists</a> who have long <a href="https://scholar.google.com/citations?user=y0lrTOoAAAAJ&hl=en&oi=ao">researched</a> the <a href="https://scholar.google.com/citations?user=y0lrTOoAAAAJ&hl=en">Medicare and Social Security programs</a>, we believe the president’s proposal is an important first step in opening the necessary debate on strengthening Medicare’s finances.</p>
<h2>Part A’s precarious funding</h2>
<p>Medicare consumes more than <a href="https://www.cbo.gov/publication/58848">15% of the federal budget</a>. The program cost $975 billion in 2022, out of the government’s <a href="https://usafacts.org/state-of-the-union/budget/">$6.5 trillion in total federal spending</a>.</p>
<p>As anyone who has enrolled in it can tell you, the program itself is rather complicated. It’s divided into three parts, known as A, B and D, each of which relies on revenue from a different mix of sources.</p>
<p>Medicare Part A covers care delivered at hospitals and nursing homes, as well as home health care. Part B pays for doctor’s visits and outpatient procedures, and Part D pays for prescription drugs. There’s also Part C, a private insurance option, known as Medicare Advantage. However, its costs are included in the accounting for Parts A and B. </p>
<p>Part A is primarily funded by a <a href="https://www.irs.gov/publications/p80">1.45% Medicare payroll tax</a> on both employees and employers. When that tax and the program’s other tax revenues don’t raise enough money to cover Part A’s costs, the program dips into the <a href="https://www.crfb.org/our-work/projects/medicare-hospital-insurance-trust-fund">Medicare Hospital Insurance trust fund</a> to make up the difference. The trust fund, amassed from past surplus payroll taxes, currently stands at around <a href="https://www.ssa.gov/oact/TRSUM/tr22summary.pdf">$143 billion</a>.</p>
<p>Without spending cuts, funding increases or a combination of the two, the Medicare program’s trustees have predicted in their annual report that the <a href="https://www.cms.gov/files/document/2022-medicare-trustees-report.pdf">Medicare trust fund</a> will be exhausted by 2028. The <a href="https://home.treasury.gov/system/files/136/TR-2022-Fact-Sheet.pdf">trustees are the secretaries</a> of the Treasury, Labor and Health and Human Services departments, plus the Social Security commissioner. There can be up to two additional trustees, but those seats are vacant.</p>
<p>Medicare’s expenses are rising rapidly with the <a href="https://www.investopedia.com/articles/personal-finance/032216/are-we-baby-boomer-retirement-crisis.asp">retirement of baby boomers</a>, the large generation of Americans born between 1946 and 1964, and <a href="https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nationalhealthaccountshistorical">rising health care costs</a>. </p>
<p>Should the trust fund be emptied out, the trustees predict that hospital benefits would have to be cut by 10%. But those cuts are widely considered to be politically unacceptable, as illustrated by <a href="https://www.whitehouse.gov/state-of-the-union-2023/">statements from Biden</a> and his predecessor, former President <a href="https://www.pbs.org/newshour/politics/read-the-full-text-of-trumps-2020-state-of-the-union">Donald Trump</a>.</p>
<p>In addition to proposing an increase in the tax levied on the <a href="https://www.irs.gov/newsroom/questions-and-answers-on-the-net-investment-income-tax">investment earnings of high-income Americans</a>, Biden also proposes that these revenues be fully dedicated to the trust fund. Currently the <a href="https://www.cms.gov/files/document/2022-medicare-trustees-report.pdf">government treats that money as general revenue</a> that can be used for <a href="https://www.thebalancemoney.com/net-investment-income-tax-3192936">any government program</a>.</p>
<h2>2 very different scenarios</h2>
<p>Unlike Medicare Part A, Parts B and D are funded largely by general federal revenue and by premiums paid by retirees.</p>
<p>Because the government is allowed to use general revenue to pay for them, the funding of Parts B and D isn’t jeopardized by the depletion of their trust fund – no matter how fast those costs rise.</p>
<p>Even without Biden’s proposed changes, official Medicare spending projections rise rapidly through the mid-2030s and then plateau as a percentage of gross domestic product.</p>
<p>However, those projections are based on a presumption that payments to <a href="https://www.cms.gov/files/document/2022-medicare-trustees-report.pdf">hospitals are constrained as specified in the Affordable Care Act</a> and that other spending constraints on <a href="https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs">physician payments</a> are realized.</p>
<p>Unfortunately, <a href="https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2015/02/02/a-primer-on-medicare-physician-payment-reform-and-the-sgr/">history provides little assurance</a> that lawmakers will maintain all of these requirements to restrain future payments to health care providers. </p>
<p>We say this because of what happened after 1997, when Congress approved the sustainable growth rate system, which was intended to limit the annual increase in cost per Medicare beneficiary to the rate of economic growth. Starting in 2002, Congress passed legislation year after year to override it – and only stopped doing that once it <a href="http://doi.org/10.1001/journalofethics.2015.17.11.pfor1-1511">did away with the system altogether in 2015</a>.</p>
<p>Reflecting this uncertainty, the annual <a href="https://www.cms.gov/files/document/2022-medicare-trustees-report.pdf">trustees report</a> features an alternative projection that is arguably more credible and more scary. It indicates that Medicare costs will grow much faster than the economy starting in 2036.</p>
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<h2>Competing demands</h2>
<p>The Social Security program, a national pension program that primarily supports older Americans, faces similar funding shortfalls.</p>
<p>Its trustees anticipate that the <a href="https://www.ssa.gov/OACT/tr/2022/tr2022.pdf">Social Security trust fund will be depleted</a> by 2035 without changes in funding, promised benefits – or both. In that event, Social Security benefits <a href="https://www.cnn.com/2023/03/08/politics/social-security-benefit-cut/index.html">may have to fall by about 20%</a> from anticipated levels. </p>
<p>Medicare and Social Security are the nation’s largest <a href="https://www.aarp.org/politics-society/government-elections/national-debt-guide/glossary/entitlements-definition.html">entitlement programs</a>. Almost all Americans, if they live long enough, will eventually be eligible to obtain these benefits – regardless of their income or wealth. </p>
<p>While Americans do not yet agree on how to put these programs on a steadier fiscal footing, the math is clear.</p>
<p>Our elected representatives cannot avoid making hard decisions that involve increasing taxes, reducing benefits or both.</p><img src="https://counter.theconversation.com/content/201360/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dennis W. Jansen does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p><p class="fine-print"><em><span>Andrew Rettenmaier does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond his academic appointment.</span></em></p>The program’s expenses are rising rapidly as baby boomers retire and health care costs grow.Dennis W. Jansen, Professor of Economics and Director of the Private Enterprise Research Center, Texas A&M UniversityAndrew Rettenmaier, Executive Associate Director of the Private Enterprise Research Center, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1995082023-03-02T19:08:43Z2023-03-02T19:08:43ZMy Health Record is meant to empower patients – but with little useful information stored, is it worth saving?<figure><img src="https://images.theconversation.com/files/512831/original/file-20230301-20-2q0zn.jpg?ixlib=rb-1.1.0&rect=52%2C22%2C4940%2C3300&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-using-modern-computer-medical-record-777148693">Shutterstock</a></span></figcaption></figure><p>Australia’s My Health Record is a national, integrated electronic record, intended to overcome the problem of having personal health information “siloed” in different systems. </p>
<p>People can access their own My Health Record via <a href="https://www.healthdirect.gov.au/my-health-record#access">MyGov</a> or an <a href="https://www.digitalhealth.gov.au/initiatives-and-programs/my-health-record/manage-your-record/view-my-health-record-using-an-app">app</a>. Any of their treating health professionals can access it, too. </p>
<p>My Health Record can hold various past information, including a shared health summary, records of health conditions, allergies and medications, <a href="https://www.pulseit.news/australian-digital-health/episoft-provides-cancer-treatment-cycle-summaries-on-my-health-record">summaries of cancer treatment</a>, test and scan results, hospital discharge notes, vaccination records, <a href="https://developer.digitalhealth.gov.au/products/australian-organ-donor-register">organ donation choices</a>, and notes entered by patients themselves. </p>
<p>But is the system actually being used? Why is it, when people access their My Health Record, they often find little helpful information? Earlier this year, Health Minister Mark Butler <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/strengthening-medicare-for-the-future">promised an overhaul</a> as part of the Strengthening Medicare Taskforce. But what needs to happen for it to be finally fit for purpose? </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/medicare-reform-is-off-to-a-promising-start-now-comes-the-hard-part-197914">Medicare reform is off to a promising start. Now comes the hard part</a>
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<h2>How many My Health Records are there?</h2>
<p>More than 90% of Australians – <a href="https://www.digitalhealth.gov.au/initiatives-and-programs/my-health-record/statistics">over 23.5 million people</a> – have a My Health Record. The rate of uptake has <a href="https://www.anao.gov.au/work/performance-audit/implementation-the-my-health-record-system">not changed much since the opt-out period ended</a>. </p>
<p>My Health Record has operated for more than ten years, undergoing a controversial change to an <a href="https://theconversation.com/opt-out-period-for-my-health-record-extended-106935">opt-out</a> system in 2018–19. The federal government has <a href="https://www.theguardian.com/australia-news/2022/jun/06/my-health-record-after-12-years-and-more-than-2bn-hardly-anyone-is-using-digital-service">invested heavily in My Health Record</a> and given <a href="https://www.servicesaustralia.gov.au/ehealth-incentives-for-practice-incentives-program?context=23046">financial incentives to general practices</a> to use it. <a href="https://mumbrella.com.au/australian-digital-health-agency-reveals-my-health-record-marketing-spend-details-530286">Large-scale communication campaigns</a> have tried to inform and educate people about it too.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/vaccination-status-when-your-medical-information-is-private-and-when-its-not-168846">Vaccination status – when your medical information is private and when it's not</a>
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<h2>What’s in them?</h2>
<p>The <a href="https://www.digitalhealth.gov.au/">Digital Health Agency</a>, which manages the My Health Record system, reports a vast number of documents have been uploaded to it: <a href="https://www.transparency.gov.au/annual-reports/australian-digital-health-agency/reporting-year/2021-22-9">some 4 billion documents by June 2022</a>. </p>
<p>Over <a href="https://www.digitalhealth.gov.au/initiatives-and-programs/my-health-record/statistics">98% of My Health Record</a> profiles have <em>something</em> in them. </p>
<p>The Digital Health Agency’s <a href="https://www.digitalhealth.gov.au/initiatives-and-programs/my-health-record/statistics">monthly reports</a> reveal that in January there were 355 million clinical documents in the My Health Record system – mainly pathology reports, but also diagnostic imaging reports, hospital discharge summaries, shared health summaries and other things. There were 494 million prescription and dispense records that had been uploaded by providers such as pharmacists and GPs. </p>
<p>This seems promising. But two things are important. </p>
<p>First, these numbers are only a small fraction of the health reports and summaries that are being generated in Australia. For instance, the health minister recently said that only <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-care-press-conference-3-february-2023">20% of diagnostic imaging reports</a> are uploaded to My Health Record. Images themselves cannot be uploaded. </p>
<p>Second, the large majority of what’s in My Health Record is simply Medicare and Pharmaceutical Benefits Scheme (PBS) data – <a href="https://www.transparency.gov.au/annual-reports/australian-digital-health-agency/reporting-year/2021-22-9">some 2 billion and 1 billion documents, respectively</a> (as of July 2022). </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/using-my-health-record-data-for-research-could-save-lives-but-we-must-ensure-its-ethical-100757">Using My Health Record data for research could save lives, but we must ensure it's ethical</a>
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<h2>How handy is this information?</h2>
<p>The usefulness of this information to patients and clinicians is limited. Medicare data contains virtually no clinically relevant information. It only provides the date of a clinic visit or a test, a brief description (such as “consultation at consulting rooms” or “iron studies”), and the provider name. This information might help a patient remember – or a provider to track – the timing of certain health events, but little else. </p>
<p>PBS prescription information in My Health Record is a little more useful – providing medicines names and doses, dates of prescription and supply, and the number of tablets and repeats. This could assist in the often-touted situation of patients attending a new doctor or the emergency department without a list of their medications. </p>
<p>Information from the Australian Immunisation Register and the Organ Donor Register is also automatically deposited in the My Health Record. Still, this type of information is fairly basic, and available <a href="https://www.servicesaustralia.gov.au/medicare-online-account">elsewhere</a>. It might not meet consumers’ expectations of their “health record”. </p>
<h2>Who is using the My Health Record?</h2>
<p>Nearly all <a href="https://www.digitalhealth.gov.au/initiatives-and-programs/my-health-record/statistics">GPs, pharmacies and public hospitals</a> in Australia are connected and “have used My Health Record”, according to the Digital Health Agency. But again, the devil is in the detail. </p>
<p>Use by specialists is still very low, with only <a href="https://www.digitalhealth.gov.au/initiatives-and-programs/my-health-record/statistics">32% registered to access the system</a>. Allied health is virtually <a href="https://www.theguardian.com/australia-news/2023/feb/03/an-improved-my-health-record-will-be-at-centre-of-push-to-modernise-primary-healthcare">absent</a>. </p>
<p><a href="https://www.digitalhealth.gov.au/initiatives-and-programs/my-health-record/statistics">Fewer than one in four people</a> viewed their My Health Record in 2022. Less than 10% of the pathology reports in the system were viewed by consumers. </p>
<p>While usage in some health sectors is rising, even public hospitals tapped little of the system’s potential, viewing <a href="https://www.digitalhealth.gov.au/initiatives-and-programs/my-health-record/statistics">fewer than 2.8 million documents</a> uploaded by another organisation, in the 12 months to January 2023. This is a tiny proportion of the My Health Record’s contents. The vast majority of documents have probably never been viewed (and even less, used), by health-care professionals or patients.</p>
<p>One of the most common arguments in favour of an integrated electronic health record is in the context of patients presenting to emergency departments. There, the ability to quickly understand a patient’s health problems, medications and recent test results could be vital. So, recent research on the use of My Health Record in emergency departments is especially telling. </p>
<p>The Australian Commission on Safety and Quality in Health Care <a href="https://www.safetyandquality.gov.au/our-work/e-health-safety/my-health-record-emergency-departments-project">analysed</a> use of My Health Record by more than 1,000 emergency department staff for 130,000 patients across four sites nationwide, in 2019. The Commission found low staff awareness of the system. My Health Record was viewed in less than 1% of emergency department presentations. And in one-third of the presentations studied, the person had an empty My Health Record.</p>
<p>A <a href="https://bmcmedinformdecismak.biomedcentral.com/articles/10.1186/s12911-022-01920-8">2021 survey</a> of a major Melbourne hospital found My Health Record “has not been adopted as routine practice in the emergency department” by most clinicians. </p>
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Read more:
<a href="https://theconversation.com/ive-given-out-my-medicare-number-how-worried-should-i-be-about-the-latest-optus-data-breach-191575">I've given out my Medicare number. How worried should I be about the latest Optus data breach?</a>
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<h2>So, is it worth saving?</h2>
<p>Consumer advocates hoped the arrival of My Health Record would <a href="http://chf.org.au/introduction-my-health-record-webinar-series/basics-my-health-record">empower consumers</a>. </p>
<p>But a <a href="https://www.theguardian.com/australia-news/2022/jun/06/my-health-record-after-12-years-and-more-than-2bn-hardly-anyone-is-using-digital-service">frustrating lack of useful content</a>, not enough <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7747035/">usable consumer resources</a>, <a href="https://www.publish.csiro.au/py/PY20169">low understanding of the system</a>, and privacy and security concerns have all contributed to a sense of missed opportunity. </p>
<p>The <a href="https://www.health.gov.au/resources/publications/strengthening-medicare-taskforce-report?language=en">Strengthening Medicare Taskforce</a> recommendations to modernise the platform could increase the information the system holds and make it easier to use. </p>
<p>But it will need investment and technical improvements to develop it beyond the “<a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-care-press-conference-3-february-2023">outdated, clunky, pdf format</a>” described by the health minister last month.</p><img src="https://counter.theconversation.com/content/199508/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Megan Prictor 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>Some 90% of Australians have a My Health Record. But even if it has health information stored on there, it might be less than informative and rarely referred to.Megan Prictor, Senior Lecturer in Law, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1993032023-02-09T19:11:35Z2023-02-09T19:11:35ZNeed a bulk-billing GP? Why throwing more money at Medicare isn’t the answer<figure><img src="https://images.theconversation.com/files/509059/original/file-20230208-19-3507v7.jpg?ixlib=rb-1.1.0&rect=1%2C2%2C997%2C663&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-doctor-consultant-having-meeting-patient-1993144466">Shutterstock</a></span></figcaption></figure><p>Last financial year, the Australian government <a href="https://budget.gov.au/2022-23-october/content/bp1/download/bp1_2022-23.pdf">spent</a> almost A$29 billion on Medicare. Most was spent on primary care – a patient’s usual first contact with the health system when sick or injured, such as GP, allied health and diagnostic services. Every year, this spending increases.</p>
<p>Yet, many patients are paying more to see their GP, some <a href="https://theconversation.com/rising-out-of-pocket-health-costs-are-a-worry-but-the-major-parties-have-barely-mentioned-it-181595">cannot afford care</a> and emergency departments are <a href="https://theconversation.com/emergency-departments-are-clogged-and-patients-are-waiting-for-hours-or-giving-up-whats-going-on-184242">overcrowded with patients</a> who could be treated by a GP.</p>
<p>Last week, the Strengthening Medicare Taskforce released its much-anticipated <a href="https://www.health.gov.au/resources/publications/strengthening-medicare-taskforce-report?language=en">report</a> on how to improve the primary health-care system. The report provided broad-brush recommendations mostly focused on delivering patient-centred care, supported by better health data and information technology.</p>
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<h2>Medicare is set for an overhaul</h2>
<p>An important subtext of the report is to overhaul Medicare, Australia’s national public health insurance scheme. Medicare pays a proportion of costs for every Australian that receives subsidised primary care services.</p>
<p>There has not been a major reform to Medicare since its introduction in 1984. If successful, reforming Medicare will be the greatest change to primary care in decades. </p>
<p>It will help governments usher in long sought-after integrated care pathways – with patients cared for by a team of health professionals that better meet their needs, especially those with <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117605/">chronic conditions</a>.</p>
<p>But let’s not celebrate just yet. Major funding reform is not a given. Health Minister Mark Butler concedes there’s a long road ahead, telling <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/radio-interview-with-minister-butler-and-sabra-lane-abc-am-9-february-2023?language=en">the ABC</a> this week that we’re not going to fix Medicare in one budget.</p>
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Read more:
<a href="https://theconversation.com/medicare-reform-is-off-to-a-promising-start-now-comes-the-hard-part-197914">Medicare reform is off to a promising start. Now comes the hard part</a>
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<h2>A battle looms ahead</h2>
<p>A potential battle between health providers and the Australian government looms on the horizon.</p>
<p>That’s because the most ferocious national health-care debates are often about how GPs should get paid. Medicare needs to pay providers based on patient health outcomes. Some providers, like GPs, may be worse off financially if they perform poorly.</p>
<p>That will be a hard pill to swallow. Pressure from strong lobby groups that represent primary care providers may water down reform. That runs the risk of worsening patient outcomes compared to what could be achieved.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/509062/original/file-20230208-19-pysvye.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Street signage of bulk-billing medical centre on high street" src="https://images.theconversation.com/files/509062/original/file-20230208-19-pysvye.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/509062/original/file-20230208-19-pysvye.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/509062/original/file-20230208-19-pysvye.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/509062/original/file-20230208-19-pysvye.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/509062/original/file-20230208-19-pysvye.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/509062/original/file-20230208-19-pysvye.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/509062/original/file-20230208-19-pysvye.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A bulk-billing GP has become harder to find. So we need widespread reform to improve access to quality, value-for-money care.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/melbourne-vicaustraliaoct-9th-2019-sign-bulk-1743252638">Shuang Li/Shutterstock</a></span>
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Read more:
<a href="https://theconversation.com/patient-advocate-or-doctors-union-how-the-ama-flexes-its-political-muscle-60444">Patient advocate or doctors' union? How the AMA flexes its political muscle</a>
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<h2>How did we get here?</h2>
<p>Successive governments over the past 30 years have tried to tighten the reins on runaway Medicare spending. Most attempts have failed.</p>
<p>The Hawke government introduced a <a href="https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/FlagPost/2014/April/GP_co-payment_lessons_from_past">$2.50 co-payment</a> in 1991, which GPs could charge to non-concessional patients when they received bulk-billed services. In 1992, Keating abolished this when he became prime minister. The Abbott government tried to introduce a $7 co-payment in 2014, but <a href="https://www.abc.net.au/news/2015-03-03/timeline-dumped-medicare-co-payment-key-events/6275260">dumped the budget announcement</a> against fierce community opposition in 2015.</p>
<p>The Abbott government did manage to freeze the annual increase in Medicare Benefits Schedule fees (fees doctors are paid to perform certain subsidised services) between 2015 and 2020. This led to fierce opposition from primary care providers.</p>
<p>The Australian Medical Association (AMA) <a href="https://ama.com.au/sites/default/files/documents/Handout%20for%20politicians_MBSIndexation%20Freeze.pdf">suggested</a> this would force GPs to increase co-payments and reduce bulk billing to maintain their business returns. </p>
<p>While co-payments <a href="https://www.aihw.gov.au/reports/health-welfare-expenditure/health-expenditure-australia-2020-21/contents/summary">have increased</a>, annual bulk billing rates have only declined in the past year.</p>
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<img alt="" src="https://images.theconversation.com/files/508789/original/file-20230208-23-wqbzej.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/508789/original/file-20230208-23-wqbzej.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=370&fit=crop&dpr=1 600w, https://images.theconversation.com/files/508789/original/file-20230208-23-wqbzej.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=370&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/508789/original/file-20230208-23-wqbzej.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=370&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/508789/original/file-20230208-23-wqbzej.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=465&fit=crop&dpr=1 754w, https://images.theconversation.com/files/508789/original/file-20230208-23-wqbzej.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=465&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/508789/original/file-20230208-23-wqbzej.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=465&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">Bulk-billing rates have only declined in the past year.</span>
<span class="attribution"><a class="source" href="https://www.pc.gov.au/ongoing/report-on-government-services/2023/health/primary-and-community-health">Productivity Commission</a></span>
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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>How should we fund primary care?</h2>
<p>It’s clear Medicare is no longer “fit for purpose”. Some patients <a href="https://www.aihw.gov.au/getmedia/f6dfa5f0-1249-4b1e-974a-047795d08223/aihw-mhc-hpf-35-patients-out-of-pocket-spending-Aug-2018.pdf.aspx?inline=true">avoid care</a> because they cannot afford it. Patients with higher incomes, and patients living in more affluent areas, often pay more if not bulk billed, but can access primary care easier.</p>
<p><a href="https://www.ama.com.au/media/medicare-report-encouraging-significantly-more-investment-needed-save-general-practice">Increasing Medicare rebates</a>, as the AMA proposes will not fix those problems. </p>
<p>A financial incentive for providers to deliver care of little value to patients <a href="https://www.mja.com.au/journal/2012/197/2/caretrack-assessing-appropriateness-health-care-delivery-australia">will remain</a>. Providers will still be paid regardless of the health outcomes they achieve, and care misaligned with best practice will continue to be funded.</p>
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Read more:
<a href="https://theconversation.com/some-gps-just-keep-their-heads-above-water-other-doctors-businesses-are-more-profitable-than-law-firms-192163">Some GPs just keep their heads above water. Other doctors' businesses are more profitable than law firms</a>
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<h2>We need a radical rethink</h2>
<p>A complete rethink of Medicare is required to support the vision presented in the Strengthening Medicare Taskforce report. The Australian government must start now, as the health-care system adjusts to a post-pandemic world.</p>
<p>Reforming Medicare cannot happen in isolation. It must sit within a cohesive national vision and a <a href="https://ahha.asn.au/publication/health-policy-issue-briefs/deeble-issues-brief-no-49-roadmap-towards-scalable-value">ten-year plan for health-care funding reform</a>.</p>
<p>Medicare reform should be accompanied by public hospital funding, private health insurance and co-payment reform – the three other major funding sources for health care – to ensure Medicare does not remain siloed while governments seek to integrate care.</p>
<p>An independent national health payment authority should be developed and tasked with designing and coordinating the implementation of funding reform. This would work closely with state and federal governments, primary health networks and local health networks. </p>
<p>It would also clarify who is responsible for which elements of funding reform and reduce the potential for duplicating efforts across states.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1621331889540808704"}"></div></p>
<h2>We need to do things differently</h2>
<p>Australia could benefit from <a href="https://ahha.asn.au/publication/health-policy-issue-briefs/deeble-issues-brief-no-49-roadmap-towards-scalable-value">payment models</a> being explored internationally. These include funding a pathway of multiple, integrated health providers – let’s say a GP working with a physio and nurse practitioner – to provide cheaper care that improves outcomes.</p>
<p>In such “value-based” payment models, there’s an incentive to improve health outcomes and reduce costs. Providers share the cost savings compared to what it would have cost using the current Medicare Benefits Schedule.</p>
<p>If we’re to reform Medicare towards paying for value, then we’ll need much more data on patient health outcomes, other factors that impact health outcomes but are outside the control of providers (such as socioeconomic factors), and data on the cost of delivering care. </p>
<p>That requires reforming the way data is collected and shared, and investment in better information technology infrastructure. </p>
<p>The government will need to work closely with providers to ensure they are equipped to manage the transition towards value-based payment models. It will also need to help providers connect and work together to coordinate different types of care.</p>
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<strong>
Read more:
<a href="https://theconversation.com/with-the-training-to-diagnose-test-prescribe-and-discharge-nurse-practitioners-could-help-rescue-rural-health-199287">With the training to diagnose, test, prescribe and discharge, nurse practitioners could help rescue rural health</a>
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<p><em>Update: the article has been updated to more accurately reflect government expenditure on Medicare.</em></p><img src="https://counter.theconversation.com/content/199303/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Henry Cutler does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Medicare needs an overhaul to improve patients’ access to quality care. And we have a unique opportunity to shake up how health care is provided.Henry Cutler, Professor and Director, Macquarie University Centre for the Health Economy, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.