tag:theconversation.com,2011:/us/topics/private-hospitals-5103/articlesPrivate hospitals – The Conversation2023-12-15T05:45:15Ztag:theconversation.com,2011:article/2199012023-12-15T05:45:15Z2023-12-15T05:45:15ZThinking about cosmetic surgery? New standards will force providers to tell you the risks and consider if you’re actually suitable<figure><img src="https://images.theconversation.com/files/565962/original/file-20231215-23-9ky8oh.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C1000%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/surgeon-hand-drawing-marks-on-female-531165886">Africa Studio/Shutterstock</a></span></figcaption></figure><p>People considering cosmetic surgery – such as a breast augmentation, liposuction or face lift – should have <a href="https://www.abc.net.au/news/2023-12-14/new-cosmetic-surgery-standards-introduced/103218180">extra protection</a> following the release this week of new safety and quality standards for providers, from small day-clinics through to larger medical organisations.</p>
<p>The <a href="https://www.safetyandquality.gov.au/sites/default/files/2023-12/national_safety_and_quality_cosmetic_surgery_standards.pdf">new standards</a> cover issues including how these surgeries are advertised, psychological assessments before surgery, the need for people to be informed of risks associated with the procedure, and the type of care people can expect during and afterwards. The idea is for uniform standards across Australia.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1735224191073575038"}"></div></p>
<p>The move is part of sweeping reforms of the cosmetic surgery industry and the <a href="https://www.medicalboard.gov.au/codes-guidelines-policies/cosmetic-medical-and-surgical-procedures-guidelines.aspx#:%7E:text=Cosmetic%20procedures%20must%20only%20be,care%20and%20any%20likely%20complications">regulation of medical practitioners</a>, including who is allowed to <a href="https://theconversation.com/doctors-may-soon-get-official-endorsements-to-practise-cosmetic-surgery-but-will-that-protect-patients-202136">call themselves a surgeon</a>.</p>
<p>It is heartening to see these reforms, but some may say they should have come much sooner for what’s considered a <a href="https://journals.sagepub.com/doi/10.1177/07488068221105360">highly unregulated</a> area of medicine.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/thinking-about-cosmetic-surgery-at-last-some-clarity-on-who-can-call-themselves-a-surgeon-196947">Thinking about cosmetic surgery? At last, some clarity on who can call themselves a surgeon</a>
</strong>
</em>
</p>
<hr>
<h2>Why do people want cosmetic surgery?</h2>
<p>Australians spent an <a href="https://www.safetyandquality.gov.au/sites/default/files/2023-12/media_infographic_cosmetic_surgery_standards.PDF">estimated A$473 million</a> on cosmetic surgery procedures in 2023.</p>
<p>The <a href="https://www.sciencedirect.com/science/article/abs/pii/S1740144518305552">major reason</a> people want cosmetic surgery relates to concerns about their body image. <a href="https://academic.oup.com/asj/article/43/9/994/7125043">Comments</a> from their partners, friends or family about their appearance is another reason. </p>
<p>The way cosmetic surgery is portrayed on <a href="https://www.sciencedirect.com/science/article/pii/S1740144522001784">social media</a> is also a factor. It’s often portrayed as an “easy” and “accessible” fix for concerns about someone’s appearance. So such aesthetic procedures have become far more normalised. </p>
<p>The use of “before” and “after” images online is also a powerful influence. Some people may think their appearance is worse than the “before” photo and so they think cosmetic intervention is <a href="https://academic.oup.com/asj/article/36/8/920/2613944?login=false">even more necessary</a>.</p>
<figure class="align-center ">
<img alt="Young woman sits cross-legged on chair" src="https://images.theconversation.com/files/565696/original/file-20231214-23-j2jz8x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/565696/original/file-20231214-23-j2jz8x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/565696/original/file-20231214-23-j2jz8x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/565696/original/file-20231214-23-j2jz8x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/565696/original/file-20231214-23-j2jz8x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/565696/original/file-20231214-23-j2jz8x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/565696/original/file-20231214-23-j2jz8x.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">Body image is a major concern. But other factors motivate people to choose cosmetic surgery.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-home-massaging-tired-painful-spider-2155356421">alinabuphoto/Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-do-normal-labia-look-like-sometimes-doctors-are-the-wrong-people-to-ask-112513">What do normal labia look like? Sometimes doctors are the wrong people to ask</a>
</strong>
</em>
</p>
<hr>
<h2>People don’t always get the results they expect</h2>
<p><a href="https://journals.lww.com/annalsplasticsurgery/abstract/2009/02000/a_prospective,_multi_center_study_of_psychosocial.5.aspx">Most people</a> are <a href="https://academic.oup.com/asj/article/40/10/1143/5722403?login=false">satisfied</a> with their surgical outcomes and feel better about the body part that was previously concerning them.</p>
<p>However, people have often paid a sizeable sum of money for these surgeries and sometimes experienced considerable pain as they recover. So a <a href="https://www.tandfonline.com/doi/full/10.1080/13548500903112374">positive evaluation</a> may be needed to justify these experiences. </p>
<p>People who are likely to be unhappy with their results are those with <a href="https://journals.lww.com/plasreconsurg/abstract/2014/10000/why_some_patients_are_unhappy__part_2_.46.aspx">unrealistic expectations</a> for the outcomes, including the recovery period. This can occur if people are not provided with sufficient information throughout the surgical process, but particularly before making their final decision to proceed.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/thinking-of-getting-a-minor-cosmetic-procedure-like-botox-or-fillers-heres-what-to-consider-first-161271">Thinking of getting a minor cosmetic procedure like botox or fillers? Here's what to consider first</a>
</strong>
</em>
</p>
<hr>
<h2>What’s changing?</h2>
<p>According to the <a href="https://www.safetyandquality.gov.au/sites/default/files/2023-12/national_safety_and_quality_cosmetic_surgery_standards.pdf">new standards</a>, services need to ensure their own advertising is not misleading, does not create unreasonable expectations of benefits, does not use patient testimonials, and doesn’t offer any gifts or inducements.</p>
<p>For some clinics, this will mean very little change as they were not using these approaches anyway, but for others this may mean quite a shift in their advertising strategy. </p>
<p>It will likely be a major challenge for clinics to monitor all of their patient communication to ensure they adhere to the standards. </p>
<p>It is also not quite clear how the advertising standards will be monitored, given the expanse of the internet.</p>
<figure class="align-center ">
<img alt="Surgeons operate on a patient" src="https://images.theconversation.com/files/565698/original/file-20231214-25-91vwt9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/565698/original/file-20231214-25-91vwt9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/565698/original/file-20231214-25-91vwt9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/565698/original/file-20231214-25-91vwt9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/565698/original/file-20231214-25-91vwt9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/565698/original/file-20231214-25-91vwt9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/565698/original/file-20231214-25-91vwt9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The new standards will govern how cosmetic surgery is advertised and promoted.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/surgical-team-performing-surgery-patient-operating-750079588">Tong Nawarit/Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/googling-for-a-new-dentist-or-therapist-heres-how-to-look-past-the-glowing-testimonials-84584">Googling for a new dentist or therapist? Here's how to look past the glowing testimonials</a>
</strong>
</em>
</p>
<hr>
<h2>What about the mental health assessment?</h2>
<p>The new standards say clinics must have processes to ensure the assessment of a patient’s general health, including psychological health, and that information from a patient’s referring doctor be used “where available”. </p>
<p>According to the <a href="https://www.medicalboard.gov.au/codes-guidelines-policies/cosmetic-medical-and-surgical-procedures-guidelines.aspx#:%7E:text=Cosmetic%20procedures%20must%20only%20be,care%20and%20any%20likely%20complications">guidelines</a> from the Medical Board of Australia, which the standards are said to complement, all patients must have a referral, “preferably from their usual general practitioner or if that is not possible, from another general practitioner or other specialist medical practitioner”.</p>
<p>While this is a step in the right direction, we may be relying on medical professionals who may not specialise in assessing body image concerns and related mental health conditions. They may also have had very little prior contact with the patient to make their clinical impressions. </p>
<p>So these doctors need further training to ensure they can perform assessments efficiently and effectively. People considering surgery may also not be forthcoming with these practitioners, and may view them as “gatekeepers” to surgery they really want to have. </p>
<figure class="align-center ">
<img alt="Surgeons discuss a patient's case" src="https://images.theconversation.com/files/565701/original/file-20231214-21-lz7rps.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/565701/original/file-20231214-21-lz7rps.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/565701/original/file-20231214-21-lz7rps.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/565701/original/file-20231214-21-lz7rps.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/565701/original/file-20231214-21-lz7rps.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/565701/original/file-20231214-21-lz7rps.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/565701/original/file-20231214-21-lz7rps.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">Ideally, mental health assessments should be done by health professionals with experience and training in body image concerns.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/plastic-cosmetic-surgeon-consults-woman-about-2147151401">Roman Fenton/Shutterstock</a></span>
</figcaption>
</figure>
<p>Ideally, mental health assessments should be performed by health professionals who are extensively trained in the area. They also know what other areas should be explored with the patient, such as the potential impact of trauma on body image concerns.</p>
<p>Of course, there are <a href="https://theconversation.com/we-cant-solve-australias-mental-health-emergency-if-we-dont-train-enough-psychologists-here-are-5-fixes-190135">not enough</a> mental health professionals, particularly psychologists, to conduct these assessments so there is no easy solution. </p>
<p>Ultimately, this area of health would likely benefit from a standard multidisciplinary approach where all health professionals involved (such as the cosmetic surgeon, general practitioner, dermatologist, psychologist) work together with the patient to come up with a plan to best address their bodily concerns. </p>
<p>In this way, patients would likely not view any of the health professionals as “gatekeepers” but rather members of their treating team.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/whats-the-connection-between-cosmetic-procedures-and-mental-health-190841">What's the connection between cosmetic procedures and mental health?</a>
</strong>
</em>
</p>
<hr>
<h2>If you’re considering cosmetic surgery</h2>
<p>The Australian Commission on Safety and Quality in Health Care, which developed the new standards, recommended taking these <a href="https://www.safetyandquality.gov.au/sites/default/files/2023-12/media_backgrounder_-_cosmetic_surgery_reforms_will_help_protect_patients_-_14_dec_2023.pdf">four steps</a> if you’re considering cosmetic surgery:</p>
<ol>
<li><p>have an independent physical and mental health assessment before you commit to cosmetic surgery</p></li>
<li><p>make an informed decision knowing the risks</p></li>
<li><p>choose your practitioner, knowing their training and qualifications</p></li>
<li><p>discuss your care after your operation and where you can go for support.</p></li>
</ol>
<p>My ultimate hope is people safely receive the care to help them best overcome their bodily concerns whether it be medical, psychological or a combination.</p><img src="https://counter.theconversation.com/content/219901/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gemma Sharp receives funding from NHMRC Investigator Grant (Emerging Leadership 2).</span></em></p>If you’re thinking of a breast augmentation, liposuction, or a face lift, this latest move is designed to provide extra protection. Here’s what you need to know ahead of surgery.Gemma Sharp, Associate Professor, NHMRC Emerging Leadership Fellow & Senior Clinical Psychologist, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1780322022-03-08T03:13:30Z2022-03-08T03:13:30ZPrivate obstetric care increases the chance of caesarean birth, regardless of health needs and wishes<figure><img src="https://images.theconversation.com/files/450312/original/file-20220307-83366-7stmow.jpg?ixlib=rb-1.1.0&rect=48%2C8%2C5365%2C2930&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/baby-being-born-via-caesarean-600w-50320798.jpg">Shutterstock</a></span></figcaption></figure><p>Women in Australia are more likely to have an unplanned caesarean birth if they give birth in a private hospital rather than a public hospital – independent of their health status during pregnancy or their birth plans. Our recent <a href="https://www.sciencedirect.com/science/article/abs/pii/S0277953622000326">study</a> showed an unplanned caesarean birth was 4.2% more likely in a private hospital compared with a public hospital. For first-time mums, it was 7.7% more likely.</p>
<p>Many <a href="https://bmjopen.bmj.com/content/bmjopen/7/8/e016600.full.pdf">studies</a> have pointed to a link between private obstetric care and higher rates of caesarean births. But it’s been difficult to tease out the effects of women who may need or want a caesarean birth. We can’t look to the gold standard of evidence in the form of a randomised trial, because it would be unfeasible and unethical to randomly assign women to public and private care. </p>
<p>Instead, in this study we focused on a large data set of over 289,000 births in NSW between 2007 and 2012, and used a method developed to approximate a randomised trial. Two-thirds of women received public care, while 27% gave birth in a private hospital (7% had a private obstetrician in a public hospital). Women in our study had low risk pregnancies right up to the start of labour and did not plan to have a caesarean. This approach took out the effect of maternal choice and health needs, leaving only the impact of care received: private or public.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-manage-pain-during-childbirth-what-the-research-says-148561">How to manage pain during childbirth: what the research says</a>
</strong>
</em>
</p>
<hr>
<h2>Two different health systems</h2>
<p>Caesarean birth is a necessary and life-saving surgery when a clinical need exists. However, caesarean birth has also been <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1111/birt.12348">linked</a> with a range of short and long term adverse child health outcomes, such as respiratory infection, eczema and metabolic disorder. So unnecessary caesarean births may involve increased risk without clear benefit. </p>
<p>In <a href="https://www.safetyandquality.gov.au/sites/default/files/2021-04/fourth_atlas_2021_-_chapter_1._early_planned_births.pdf">Australia</a>, 35% of all babies were born via caesarean birth in 2017. Of the surgeries performed before the pregnancy was full term, over 40% were without a medical reason. Some of this is due to maternal choice, but international studies have shown that <a href="https://academic.oup.com/eurpub/article/15/3/288/483999">convenience</a> and <a href="https://www.sciencedirect.com/science/article/abs/pii/S0167629699000090">payment</a> to the doctor or hospital also matter.</p>
<p>In Australia, the way hospitals and providers are paid could be an important factor in birth outcomes. Private doctors and hospitals are employed and paid differently from their public counterparts, so they face different incentives to intervene during labour and childbirth. </p>
<p>Private obstetricians are paid on a fee-for-service basis to attend the birth. By contrast, publicly appointed obstetric and midwifery staff are <a href="https://www1.health.nsw.gov.au/pds/ArchivePDSDocuments/IB2019_028.pdf">paid</a> on a salary basis for agreed hours. This means private obstetricians receive more income, the more births they can attend. In some <a href="https://academic.oup.com/qje/article-abstract/123/2/795/1930885">cases</a>, caesarean birth may also be seen as a method of risk management given the uncertainty of prolonged labour.</p>
<p>Hospitals also receive different payment based on whether a birth was caesarean or vaginal, reflecting the relative complexity of caesarean birth. Caesarean birth is a <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/1D47CB6E5326A3C8CA257BF000217984/$File/The%20HCP%20Annual%20Report%202019-20.xlsx">high-cost procedure</a>: an average A$11,782 charge for caesarean birth, compared to A$8,388 for a vaginal birth in a private hospital. In our study, there were more than 3,200 “extra” caesarean births in private hospitals, that is, births that would have been vaginal births in the public system.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1498576596651081729"}"></div></p>
<h2>Private choices, caesarean outcomes</h2>
<p>In Australia, women who give birth in a public hospital have care provided by appointed midwives and obstetricians. If they have the resources, some women may decide to pay for care from a private obstetrician of their choice, either at a private or a public hospital (with reimbursement from their private health insurer). For women who wish to schedule a caesarean birth without health reasons – as a matter of convenience or because they are nervous about vaginal birth – private care is often the only option. </p>
<p>Our research is the first to measure the impact on the type of birth of having a private obstetrician in a public hospital, as well as the impact of giving birth in a private hospital. </p>
<p>We found a smaller effect of having a private obstetrician in a public hospital, which raised the probability of caesarean birth by 2.1%. This could be due to the influence of both the culture in a less-interventionist birth unit led by midwives, as well as the dominance of appointed staff, in public hospitals. </p>
<p>By contrast, we found a larger increase of 4.2% for women who gave birth in private hospitals. Aside from possible payment and convenience incentives, this could also be due to the more interventionist culture in private hospitals. Again, these increases in the likelihood of a caesarean birth were independent of health need at the onset of labour or prior birthing intention. While many caesarean births may occur due to complications during labour, there is no evidence to suggest these complications are more common in private hospitals. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/450313/original/file-20220307-85251-18eskka.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="woman holds very young baby close" src="https://images.theconversation.com/files/450313/original/file-20220307-85251-18eskka.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/450313/original/file-20220307-85251-18eskka.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/450313/original/file-20220307-85251-18eskka.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/450313/original/file-20220307-85251-18eskka.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/450313/original/file-20220307-85251-18eskka.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/450313/original/file-20220307-85251-18eskka.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/450313/original/file-20220307-85251-18eskka.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">Caesarean births cost the system more than vaginal births.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/portrait-images-half-african-thai-600w-1922320169.jpg">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/vaginal-birth-after-caesarean-increases-the-risk-of-serious-perineal-tear-by-20-our-large-scale-review-shows-173249">Vaginal birth after caesarean increases the risk of serious perineal tear by 20%, our large-scale review shows</a>
</strong>
</em>
</p>
<hr>
<h2>Valuing autonomy</h2>
<p>Our results have meaningful implications for women choosing their antenatal and birth care, as well as the health system supporting them. Women <a href="https://www.sciencedirect.com/science/article/abs/pii/S0002937802701890">value</a> their autonomy and participation in the decision-making process when it comes to labour and childbirth.</p>
<p>Women may choose a private obstetrician for reasons of continuity of care or because of a recommendation. They may prefer the amenities in a private hospital. Our study adds to a <a href="https://bmjopen.bmj.com/content/7/8/e016600.abstract">body of evidence</a> about the likelihood of surgical intervention in different settings. Women should seek information about their care choices and advocate for their preferences around intervention with their midwife or doctor.</p>
<p>Unnecessary caesarean births mean we are not using scarce health system resources in the best way. This research calls for a rethink of the Australian private health insurance system, which supports this diversion of funding and specialists towards unnecessary care that could carry increased risks for birthing mother and child.</p><img src="https://counter.theconversation.com/content/178032/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Serena Yu receives funding from the National Health and Medical Research Council which supported this research. She also currently receives funding from the Medical Research Future Fund.</span></em></p><p class="fine-print"><em><span>Caroline Homer receives funding from National Health and Medical Research Council which supported this research. She is a Life Member of the Australian College of Midwives and the immediate Past President.
</span></em></p><p class="fine-print"><em><span>Denzil G Fiebig receives funding from the National Health and Medical Research Council which supported this research. He also currently receives funding from the Medical Research Future Fund.</span></em></p><p class="fine-print"><em><span>Rosalie Viney receives funding from the National Health and Medical Research Council that supported this research.
</span></em></p><p class="fine-print"><em><span>Vanessa Scarf receives National Health and Medical Research Council which supported this research. She works as a midwife in a hospital on a casual basis. She also worked on the NHMRC funded Birthplace in Australia Study as the Project Coordinator.</span></em></p>We looked at almost 300,000 births and found those mothers in the private system were more likely to have a caesarean – even if they didn’t really want or need one.Serena Yu, Associate Professor, University of Technology SydneyCaroline Homer, Co-Program Director: Maternal and Child Health, Burnet InstituteDenzil G Fiebig, Professor, UNSW SydneyRosalie Viney, Professor of Health Economics, University of Technology SydneyVanessa Scarf, Lecturer in Midwifery, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1752332022-01-20T04:06:41Z2022-01-20T04:06:41ZOmicron is overwhelming Australia’s hospital system. 3 emergency measures aim to ease the burden<p>Public hospitals – never with much spare capacity – have been severely stressed by the latest COVID wave.</p>
<p>The current Omicron outbreak has loaded even heavier demands on hospital beds, both for those who need oxygen and for the severely ill in intensive care wards, as well as those who cannot be cared for at home or in an aged-care facility.</p>
<p>Shortages of beds and hospital equipment are matched by staffing problems as front-line workers <a href="https://www.theguardian.com/australia-news/2022/jan/03/covid-positive-nurses-are-working-in-nsw-hospitals-due-to-severe-staffing-shortages">catch COVID</a>, are contacts of cases, or are emotionally and physically <a href="https://7news.com.au/lifestyle/health-wellbeing/nsw-records-17-deaths-29504-covid-cases-c-5336468">exhausted</a>.</p>
<p>Staff are angry having to provide intensive care beds for people who choose not to be vaccinated and then get seriously ill. </p>
<p>Intensive care nurses in Sydney <a href="https://www.news.com.au/national/new-south-wales-icu-nurses-strike/video/3d88eba2d883e3b3462171a950bcd5b0">began strike action</a> outside Westmead Hospital on Wednesday to protest dangerous work conditions and low staffing levels.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1482494995634753544"}"></div></p>
<p>Many of our hospitals were not equipped to face an enemy like COVID.</p>
<p>Now, three emergency measures will help us muddle through the crisis, caused in part by the removal of public health controls just before the social festive season which commentators have referred to as “letting it rip”.</p>
<p>The combined effects of these short-term measures should enable us to cope with the pressures of increased numbers of patients requiring care.</p>
<p>But the sheer number of cases of Omicron, even if is milder than the Delta variant and assuming case numbers decline, will test these arrangements to the limit.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/from-covid-control-to-chaos-what-now-for-australia-two-pathways-lie-before-us-174325">From COVID control to chaos – what now for Australia? Two pathways lie before us</a>
</strong>
</em>
</p>
<hr>
<h2>1. Reinforcing the front line</h2>
<p>In Victoria, a “<a href="https://www.abc.net.au/news/2022-01-19/what-is-code-brown-emergency-in-victorian-hospitals/100765890">Code Brown</a>” has been implemented across the hospital system.</p>
<p>It means staff of major city and regional public hospitals may have their leave cancelled and be allocated to work where needs are greatest. Non-urgent care may be postponed.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1483381096566095873"}"></div></p>
<p>It’s designed to allow the hospitals to compensate for thousands more patients and several thousand fewer staff, off work because of COVID.</p>
<p>This is the first time the code has been used statewide.</p>
<p>It’s designed to respond to an emergency, such as a road accident, bushfire or other natural disaster.</p>
<h2>2. Recruiting the private sector</h2>
<p>The federal government has agreed <a href="https://www.abc.net.au/news/2022-01-18/private-hospitals-take-public-patients-omicron-covid-pressure/100764512">private hospitals should work with public hospitals</a> to care for COVID patients.</p>
<p>During the pandemic, most COVID patients have been treated in the public sector.</p>
<p>Health minister Greg Hunt said this week up to 57,000 nurses and thousands of support staff from private hospitals would be available to work in public hospitals.</p>
<p>This contingency plan was enacted in 2020 and held in reserve. Now it’s needed because of short staffing in the public sector because of the load and absenteeism of staff.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1483688361894236165"}"></div></p>
<p>The details – including wages – would be left to the states to determine. </p>
<p>This move should ease the pressure on public hospitals. But a nurse or other health worker from a private hospital working in a public hospital environment encounters yet more stress. It’s rather like moving between countries – language and customs vary, and in the strict, protocol-driven environment of the modern hospital, these differences can be dangerous.</p>
<p>The workers to be drawn from the private sector were not idle before the call-up. It is not clear who, if anyone, will do the work these people did previously in the private sector, which provides much elective surgery. Further delays and cancellations of surgery may result.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/were-two-frontline-covid-doctors-heres-what-we-see-as-case-numbers-rise-167195">We're two frontline COVID doctors. Here's what we see as case numbers rise</a>
</strong>
</em>
</p>
<hr>
<h2>3. Elective surgeries postponed</h2>
<p>Elective surgery – that is, non-urgent surgery – will be reduced in public hospitals across many parts of the country, if not completely cancelled. This includes hip and knee replacements and surgery for many problems other than emergencies.</p>
<p>This action has been taken at several stress points in the past two years.</p>
<p>For those people depending on Medicare and public hospitals for hip surgery, for example, this will mean further delays.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1483953254690336769"}"></div></p>
<p>There’s much to be learned from the experience in all sectors of the health enterprise – hospitals, general practice, public health, and health service management – from the successes and mistakes in how we’ve managed COVID. </p>
<p>When the COVID war is over, it will be time for forensic soul searching to enable us to build a modern and better health system.</p>
<p>We have done well, but not as well as we might.</p><img src="https://counter.theconversation.com/content/175233/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Leeder does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A public health expert explains emergency measures recently brought in to manage the impact of Omicron on our stressed health system.Stephen Leeder, Emeritus Professor, Menzies Centre for Health Policy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1411222020-06-21T20:07:59Z2020-06-21T20:07:59Z7 lessons for Australia’s health system from the coronavirus upheaval<figure><img src="https://images.theconversation.com/files/342917/original/file-20200619-70404-17mxbp1.jpg?ixlib=rb-1.1.0&rect=7%2C7%2C4913%2C3245&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The COVID-19 pandemic forced us all to change the way we live. The lockdown altered fundamental aspects of our lives, not only to protect our own health but also the health and lives of others.</p>
<p>Just as Australians have shown a remarkable ability to adapt to a world with COVID-19, so too has Australia’s health system. In a <a href="https://grattan.edu.au/home/health/">report released today</a>, the Grattan Institute outlines seven key lessons that can help make the health system more effective, efficient and equitable, and better able to deal with future crises.</p>
<p><a href="https://theconversation.com/newsletter"><img src="https://images.theconversation.com/files/320030/original/file-20200312-116261-a6ugi0.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=90&fit=crop&dpr=2" alt="Sign up to The Conversation" width="100%"></a></p>
<h2>Lesson 1: telehealth works</h2>
<p>Since mid-March, Australians have been able to consult their GP or a specialist from the comfort of their own homes, via phone or video (known as telehealth). Although face-to-face consultations are sometimes still necessary, the pandemic has shown the enormous potential for telehealth to provide more efficient care in many instances, such as for routine appointments or <a href="https://theconversation.com/coronavirus-has-boosted-telehealth-care-in-mental-health-so-lets-keep-it-up-137381">mental health check-ups</a>.</p>
<p>During the pandemic, telehealth was a no-brainer to protect patients and health professionals from getting sick or making others sick. But given its <a href="https://www.abc.net.au/news/2020-05-05/move-to-telehealth-is-here-to-stay-after-coronavirus/12212680">widespread adoption and success</a>, it is also a no-brainer for telehealth to become a permanent fixture of health care in Australia.</p>
<p>The federal government should revise the temporary telehealth Medicare items to ensure they promote continuity of care and make them more appropriate for the longer term, couple them with e-referrals (to replace the museum-era fax machines), and introduce rules to prevent rorting.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-has-boosted-telehealth-care-in-mental-health-so-lets-keep-it-up-137381">Coronavirus has boosted telehealth care in mental health, so let's keep it up</a>
</strong>
</em>
</p>
<hr>
<h2>Lesson 2: out-of-hospital care also works</h2>
<p>Alongside telehealth, the pandemic prompted a rapid expansion of hospital-in-the-home care, including new “<a href="https://www.theguardian.com/australia-news/2020/may/13/the-genie-is-out-of-the-bottle-telehealth-points-way-for-australia-post-pandemic">virtual hospitals</a>”. Many people with chronic health conditions, or who are in rehabilitation or residential aged care, can be monitored by health professionals and given health advice without face-to-face contact, using technologies such as telemonitoring. </p>
<p>Commonwealth and state governments should fund further expansion of these services.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-hospital-in-the-home-revolution-has-been-stalled-by-covid-19-but-its-still-a-good-idea-130058">The 'hospital in the home' revolution has been stalled by COVID-19. But it's still a good idea</a>
</strong>
</em>
</p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/342918/original/file-20200619-70429-15ltnxx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/342918/original/file-20200619-70429-15ltnxx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=316&fit=crop&dpr=1 600w, https://images.theconversation.com/files/342918/original/file-20200619-70429-15ltnxx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=316&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/342918/original/file-20200619-70429-15ltnxx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=316&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/342918/original/file-20200619-70429-15ltnxx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=398&fit=crop&dpr=1 754w, https://images.theconversation.com/files/342918/original/file-20200619-70429-15ltnxx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=398&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/342918/original/file-20200619-70429-15ltnxx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=398&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Telehealth consultations have become more commonplace during the pandemic.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>Lesson 3: Australia needs new funding arrangements for general practices</h2>
<p>Australia’s rigid primary care funding model, in which doctors are paid on a fee-for-service basis, made it hard for GPs to set up new practice models during the pandemic – such as quickly establishing COVID-19 testing clinics or making outreach calls to vulnerable patients. </p>
<p>Governments should remove barriers in the Medicare system to allow for different models of care.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/4-ways-australias-coronavirus-response-was-a-triumph-and-4-ways-it-fell-short-139845">4 ways Australia's coronavirus response was a triumph, and 4 ways it fell short</a>
</strong>
</em>
</p>
<hr>
<h2>Lesson 4: public and private systems should be more integrated</h2>
<p>The pandemic showed the potential for public and private health-care systems to work better together. Private hospitals were set up to deal with the overflow from potentially overwhelmed public hospitals. At the same time, private hospitals effectively came to a halt when governments suspended non-urgent elective surgeries, to free up resources to tackle the pandemic.</p>
<p>Now there is a huge backlog of patients who need elective surgeries. Clearing this backlog should not be a business-as-usual matter. The pandemic provides an opportunity for Australia to move away from the current inconsistent wait-list process, to a standardised, efficient, equitable process with a single wait-list priority system to properly manage elective surgeries. </p>
<p>State governments should also consider negotiating long-term contracts with private hospitals for extra help.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/elective-surgerys-due-to-restart-next-week-so-nows-the-time-to-fix-waiting-lists-once-and-for-all-136835">Elective surgery's due to restart next week so now's the time to fix waiting lists once and for all</a>
</strong>
</em>
</p>
<hr>
<h2>Lesson 5: there are gaps in Australia’s pandemic preparedness</h2>
<p>Despite Australia’s <a href="https://theconversation.com/4-ways-australias-coronavirus-response-was-a-triumph-and-4-ways-it-fell-short-139845">largely successful response</a> to the pandemic, our preparedness regime was not totally up to scratch. Australia had not contemplated a crisis of this scale, and as a consequence the early response was characterised by reactive policy-making and mixed messages to the public.</p>
<p>Future pandemic planning should include a workforce strategy to support the rapid expansion of health-care capacity; provide a national surveillance approach to quick and accurate reporting of disease data; and ensure that secondary health effects such as mental health problems and domestic violence are built into the plan and managed in the longer term.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-are-the-characteristics-of-strong-mental-health-139032">What are the characteristics of strong mental health?</a>
</strong>
</em>
</p>
<hr>
<h2>Lesson 6: the health system needs a stronger supply chain</h2>
<p>During the pandemic, health workers had to cope with <a href="https://www.theguardian.com/world/2020/mar/17/coronavirus-australian-doctors-report-unacceptable-shortages-of-protective-equipment">inadequate supplies</a> of testing kits and personal protective equipment (PPE) such as face masks. Problems with Australia’s supply chains hampered ready access to supplies, and the global surge in demand forced Australian health departments to join the global bidding for fast-tracked supplies from overseas.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/342919/original/file-20200619-70391-1mp4f63.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/342919/original/file-20200619-70391-1mp4f63.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/342919/original/file-20200619-70391-1mp4f63.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/342919/original/file-20200619-70391-1mp4f63.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/342919/original/file-20200619-70391-1mp4f63.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/342919/original/file-20200619-70391-1mp4f63.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/342919/original/file-20200619-70391-1mp4f63.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">We’ve seen shortages of PPE during the pandemic.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Australian governments need to strengthen local supply chains, by drawing on a diverse set of suppliers and increasing product standardisation to enable easier substitution of products. The <a href="https://www.health.gov.au/initiatives-and-programs/national-medical-stockpile">National Medical Stockpile</a> also needs to be reviewed, because it did not have sufficient supplies.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/supplies-needed-for-coronavirus-healthcare-workers-89-million-masks-30-million-gowns-2-9-million-litres-of-hand-sanitiser-a-month-134786">Supplies needed for coronavirus healthcare workers: 89 million masks, 30 million gowns, 2.9 million litres of hand sanitiser. A month.</a>
</strong>
</em>
</p>
<hr>
<h2>Lesson 7: Commonwealth and state governments can better coordinate primary care</h2>
<p>The creation of the <a href="https://theconversation.com/au/topics/national-cabinet-84783">National Cabinet</a> improved national coordination in response to the pandemic, as the old fractured federal relationships were temporarily set aside.</p>
<p>Renewed cooperation through primary care agreements, and strengthened Primary Health Networks, could reduce – or, better still, end – the overlap in services provided by the Commonwealth and states, and improve primary care delivery.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-national-cabinets-in-and-coags-out-its-a-fresh-chance-to-put-health-issues-on-the-agenda-but-there-are-risks-140165">The national cabinet's in and COAG's out. It's a fresh chance to put health issues on the agenda, but there are risks</a>
</strong>
</em>
</p>
<hr>
<h2>The new normal can be better than the old</h2>
<p>Australia’s health care must not “snap back” to the old order. The pandemic has shown us a better way. Now reform is needed to transform these temporary improvements into long-term successes.</p>
<p>But reform and a “new normal” won’t just happen automatically. Consumers and clinicians should be engaged now to build on what went well during the pandemic, to ensure our health system is better than it ever was before the pandemic.</p><img src="https://counter.theconversation.com/content/141122/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities, as disclosed on its website.</span></em></p><p class="fine-print"><em><span>Anika Stobart 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>From the benefits of telehealth to the importance of integrating public and private systems, the COVID-19 pandemic offers several valuable lessons for Australia’s health system.Stephen Duckett, Director, Health Program, Grattan InstituteAnika Stobart, Associate, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1368352020-04-22T03:55:49Z2020-04-22T03:55:49ZElective surgery’s due to restart next week so now’s the time to fix waiting lists once and for all<figure><img src="https://images.theconversation.com/files/329614/original/file-20200422-82650-k0jniv.jpg?ixlib=rb-1.1.0&rect=14%2C0%2C4969%2C3325&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Monkey Business Images/Shutterstock</span></span></figcaption></figure><p>The near-total shutdown of elective surgery across Australia <a href="https://www.abc.net.au/news/2020-04-21/coroanvirus-national-cabinet-elective-surgery-ivf-to-resume/12168770">will end soon</a>, following National Cabinet consideration on Tuesday.</p>
<p>The shutdown was imposed to ensure there would be enough personal protective equipment (PPE) for doctors and nurses to manage a projected tsunami of COVID-19 patients in our hospitals.</p>
<p>But now there is a big backlog of Australians waiting for elective procedures.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/good-news-on-elective-surgery-but-dire-warning-on-the-economy-136745">Good news on elective surgery, but dire warning on the economy</a>
</strong>
</em>
</p>
<hr>
<p>Elective surgery waiting times are the bane of every state health minister’s life. Better ways to manage such procedures could be a major benefit from the shutdown and restart.</p>
<p>But we have to act quickly if we are to change how we manage these wait lists, as federal Health Minister Greg Hunt <a href="https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/elective-surgery-restrictions-eased">wants a staged reintroduction</a> to begin on April 27. </p>
<h2>Rethink priorities</h2>
<p>Currently, elective surgery is <a href="https://meteor.aihw.gov.au/content/index.phtml/itemId/598034">classified</a> as urgent (category 1), semi-urgent (category 2) and non-urgent (category 3). But different hospitals and different surgeons actually classify patients in different ways. </p>
<p>What’s worse is that some procedures are undoubtedly unnecessary, such as spinal fusion or removing healthy ovaries during a hysterectomy, and would provide no value for the patient, as <a href="https://theconversation.com/hospitals-have-stopped-unnecessary-elective-surgeries-and-shouldnt-restart-them-after-the-pandemic-136259">Adam Elshaug and I have argued before</a>.</p>
<p>Of course, not all of the backlog is low-value procedures. As states consider how to recommence elective surgery, they should seize this opportunity to introduce new systems, especially in metropolitan areas.</p>
<p>A properly managed elective procedures system should have three key elements:</p>
<ul>
<li><p>there should be a consistent process for assessing a patient’s need for the procedure, and ranking that patient’s priority against others</p></li>
<li><p>the team performing the procedure, and caring for the patient afterwards, should be highly experienced in the procedure</p></li>
<li><p>the procedure should be performed at an efficient hospital or other facility, so the cost to the health system is as low as possible.</p></li>
</ul>
<p>Unfortunately, Australia sometimes fails on all three measures.</p>
<h2>Stop the inconsistencies</h2>
<p>There is no consistent assessment process across hospitals. Even different surgeons in the same hospital seeing the same patient sometimes make different recommendations about the need for a procedure.</p>
<p>This means a patient lucky enough to be seen at hospital A may be assigned to category 2, but the same patient seen at hospital B might be assigned to category 3 and so have to wait longer.</p>
<p>Patient characteristics, such as <a href="https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-016-0302-3" title="Inequity in waiting for cataract surgery - an analysis of data from the Swedish National Cataract Register">gender</a> or <a href="https://link.springer.com/article/10.1186/1472-6963-12-268" title="Socioeconomic differences in waiting times for elective surgery: a population-based retrospective study">level of education</a>, also seem to inappropriately affect categorisation decisions.</p>
<p>High-volume hospitals and other facilities generally have <a href="https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-016-0376-4" title="Relationship between surgeon volume and outcomes: a systematic review of systematic reviews">better outcomes for a given procedure than low-volume centres</a>. And they are more efficient. </p>
<p>Yet most states ignore these facts. They have done little to <a href="https://www.dhhs.vic.gov.au/publications/targeting-zero-review-hospital-safety-and-quality-assurance-victoria">rationalise services</a> for the benefit of both the patient and the taxpayer.</p>
<h2>Time for change</h2>
<p>The large backlog of demand creates the opportunity for a new way of doing things. States should develop agreed assessment processes for high-volume procedures, such as knee and hip replacements and cataract operations, and reassess all patients on hospital waiting lists. </p>
<p>Reassessment could be done remotely using telehealth. Specialists in each area should be invited to develop evidence-based criteria for setting priorities. Where appropriate, patients should be diverted to treatment options other than surgery. </p>
<p>Private health insurers should be empowered to participate in <a href="https://grattan.edu.au/wp-content/uploads/2019/11/925-Saving-private-health-1.pdf">funding diversion options</a> so patients are able to have their rehabilitation at home rather than in a hospital bed.</p>
<p>A new, coordinated, single waiting list priority system in each state would enable all patients to know where they stand. A patient on the top of the list would be offered the first available place, regardless of whether it was closest to their home.</p>
<p>They could refuse the offer, without losing their place in the queue, if they wanted to wait for a closer location.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/329624/original/file-20200422-82645-jzlull.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/329624/original/file-20200422-82645-jzlull.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/329624/original/file-20200422-82645-jzlull.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=460&fit=crop&dpr=1 600w, https://images.theconversation.com/files/329624/original/file-20200422-82645-jzlull.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=460&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/329624/original/file-20200422-82645-jzlull.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=460&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/329624/original/file-20200422-82645-jzlull.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=578&fit=crop&dpr=1 754w, https://images.theconversation.com/files/329624/original/file-20200422-82645-jzlull.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=578&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/329624/original/file-20200422-82645-jzlull.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=578&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The health minister says it’s up to hospitals to decide which patients get to undergo elective surgery.</span>
<span class="attribution"><span class="source">Roman Zaiets/Shutterstock</span></span>
</figcaption>
</figure>
<p>The single waiting list should include both regional and metropolitan patients, to ensure as much as possible that city patients do not get faster treatment than people in regional and remote area. </p>
<p>Patients with private health insurance can <a href="https://www.healthdirect.gov.au/understanding-the-public-and-private-hospital-systems">opt to be treated as a private patient </a>in a public hospital. So the waiting list should include public and private patients, to prevent private patients gaining faster admission to public hospitals.</p>
<p>The system should be further centralised in metropolitan areas. The full range of elective procedures should not be re-established in every hospital. Some surgeons would need to be offered new appointments if elective surgery in their specialty was no longer being performed at the hospital where they previously had their main appointment.</p>
<h2>Private hospitals can help</h2>
<p>The private hospital system has taken a battering during the pandemic. <a href="https://www.theguardian.com/world/2020/mar/28/australias-private-hospitals-face-closure-after-coronavirus-causes-elective-surgery-ban">Private hospitals have effectively been closed</a>, and their viability may be under pressure.</p>
<p>States should consider signing contracts with private hospitals, at or below the <a href="https://www.ihpa.gov.au/what-we-do/national-efficient-price-determination">public hospital efficient price</a>, for elective procedures to be performed in these hospitals to help clear the elective surgery backlog.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/needless-treatments-spinal-fusion-surgery-for-lower-back-pain-is-costly-and-theres-little-evidence-itll-work-91829">Needless treatments: spinal fusion surgery for lower back pain is costly and there's little evidence it'll work</a>
</strong>
</em>
</p>
<hr>
<p>As part of the new service model, states should bolster their <a href="https://www.mja.com.au/journal/2012/197/9/meta-analysis-hospital-home">hospital-in-the-home systems</a>. For many patients, rehabilitation at home or as an outpatient can produce <a href="https://www.mja.com.au/journal/2018/209/5/predictors-inpatient-rehabilitation-after-total-knee-replacement-analysis">better outcomes than in-hospital rehabilitation</a>.</p>
<p>The pandemic is not over yet and policymakers are right to be turning their minds to the transition back to something approaching business as usual. But the new, post-pandemic normal should be nothing like the old.</p>
<p>Physical distancing seems to be beating the virus, but the second victim might be health reform. Not wasting the crisis is the cliché on everyone’s lips. Australia has the chance to improve our elective surgery system. For the sake of taxpayers and patients, we should grasp it.</p><img src="https://counter.theconversation.com/content/136835/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities, as disclosed on its website.</span></em></p>The COVID-19 pandemic gives us a chance to improve our elective surgery system when it restarts.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1362592020-04-16T03:04:47Z2020-04-16T03:04:47ZHospitals have stopped unnecessary elective surgeries – and shouldn’t restart them after the pandemic<figure><img src="https://images.theconversation.com/files/328245/original/file-20200416-140729-1f1dm3w.jpg?ixlib=rb-1.1.0&rect=62%2C161%2C5928%2C3206&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/illness-asia-patient-women-hospital-concept-546904408">Shutterstock</a></span></figcaption></figure><p>Part of Australia’s response to the coronavirus pandemic was a severe reduction in elective surgery, and so private hospitals have stood almost empty for a month now. </p>
<p>People who might otherwise have had a procedure are experiencing <a href="https://www.cancer.gov/publications/dictionaries/cancer-terms/def/watchful-waiting">“watchful waiting”</a>, where their condition is monitored to assess how it develops rather than having a surgical procedure. </p>
<p>The big question is whether all those procedures which didn’t happen were even necessary. There has now been a steady stream of work which suggests many procedures don’t provide any benefits to patients at all – so called low- or no-value care.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dodgy-treatment-its-not-us-its-the-other-lot-say-the-experts-so-who-do-we-believe-124638">Dodgy treatment: it's not us, it's the other lot, say the experts. So who do we believe?</a>
</strong>
</em>
</p>
<hr>
<p>Bringing about change in health policy is usually difficult (or slow, at best) because it’s like turning a big ship around. But in the past six weeks that ship has made a sudden about-turn. </p>
<p>Australia’s elective procedure system after the pandemic should be different from before the pandemic. We should dramatically reduce the number of low- or no-value procedures.</p>
<h2>What is low- or no-value health care?</h2>
<p><a href="https://www.thelancet.com/series/right-care">Low- or no-value health care</a> mean the intervention provides no or very little benefit to patients, or where the risk of harm exceeds the likely benefit. </p>
<p>Reducing such “care” <a href="https://onlinelibrary.wiley.com/doi/abs/10.5694/mja14.01664">will improve</a> both health outcomes for patients and the efficiency of the health system.</p>
<p>Research in New South Wales public hospitals <a href="https://qualitysafety.bmj.com/content/28/3/205">showed up to 9,000 low-value operations were performed in just one year</a>, and these consumed almost 30,000 hospital bed days that could have been used for high-value care. </p>
<p>One example of low-value care is <a href="https://theconversation.com/needless-treatments-spinal-fusion-surgery-for-lower-back-pain-is-costly-and-theres-little-evidence-itll-work-91829">spinal fusion surgery for low back pain</a>. This is <a href="https://orthoinfo.aaos.org/en/treatment/spinal-fusion/">a procedure on the small bones in the spine</a>, essentially welding them together. The alternative is pain management, physiotherapy and exercise.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/328250/original/file-20200416-140697-1gryh4z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/328250/original/file-20200416-140697-1gryh4z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=421&fit=crop&dpr=1 600w, https://images.theconversation.com/files/328250/original/file-20200416-140697-1gryh4z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=421&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/328250/original/file-20200416-140697-1gryh4z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=421&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/328250/original/file-20200416-140697-1gryh4z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=529&fit=crop&dpr=1 754w, https://images.theconversation.com/files/328250/original/file-20200416-140697-1gryh4z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=529&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/328250/original/file-20200416-140697-1gryh4z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=529&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Spinal fusion for low back pain is an example of low-value care.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-has-low-back-pain-789555475">Shutterstock</a></span>
</figcaption>
</figure>
<p>The <a href="https://qualitysafety.bmj.com/content/28/3/205">NSW analysis revealed</a> up to 31% of all spinal fusions were inappropriate. But even this figure is likely an <a href="https://qualitysafety.bmj.com/content/early/2020/03/12/bmjqs-2019-010564">underestimate</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/needless-treatments-spinal-fusion-surgery-for-lower-back-pain-is-costly-and-theres-little-evidence-itll-work-91829">Needless treatments: spinal fusion surgery for lower back pain is costly and there's little evidence it'll work</a>
</strong>
</em>
</p>
<hr>
<p>Other <a href="https://theconversation.com/australians-are-undergoing-unnecessary-surgery-heres-what-we-can-do-about-it-46089">examples include</a>:</p>
<ul>
<li><p>vertebroplasty for osteoporotic spinal fractures: surgery to fill a backbone (vertebrae) with cement</p></li>
<li><p>knee arthroscopy for osteoarthritis: inserting a tube to remove tissue</p></li>
<li><p>laparoscopic uterine nerve ablation for chronic pelvic pain: surgery to destroy a ligament that contains nerve fibres</p></li>
<li><p>removing healthy ovaries during a hysterectomy</p></li>
<li><p>hyperbaric oxygen therapy (breathing pure oxygen in a pressurised room) for a range of conditions including osteomyelitis (inflammation of the bone), cancer, and non-diabetic wounds and ulcers.</p></li>
</ul>
<p>Low-value care can harm patients because of the risks inherent in any procedure. If a patient having a low-value procedure gets even one complication, the time they spend in hospital <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2725081">doubles, on average</a>.</p>
<p>For some patients, the hospital stay can be much longer. For example, a low-value <a href="https://www.healthdirect.gov.au/arthroscopy">knee arthroscopy</a> with no complications consumes one bed day. If a complication occurs, that length of stay <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2725081">increases to 11 days</a>, on average. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/needless-procedures-knee-arthroscopy-is-one-of-the-most-common-but-least-effective-surgeries-102705">Needless procedures: knee arthroscopy is one of the most common but least effective surgeries</a>
</strong>
</em>
</p>
<hr>
<p>For most low-value procedures, the most common complication is infection.</p>
<p>The situation is even worse in private hospitals, where a <a href="https://treasury.gov.au/sites/default/files/2019-03/private_healthcare_australia.pdf">much greater proportion of elective procedures are low value</a>.</p>
<h2>Prioritise treatments that work</h2>
<p>Most state health departments and private insurers now know the size of the low-value care problem and which hospitals are providing that “care”. </p>
<p>Due to the COVID-19 response, the tap for these procedures has been turned down for some and off for others. This is a <a href="https://theconversation.com/the-coronavirus-ban-on-elective-surgeries-might-show-us-many-people-can-avoid-going-under-the-knife-135325">risk for some patients</a>, but others will benefit from not having the surgery. We must grasp the opportunity to learn from this enforced break.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-coronavirus-ban-on-elective-surgeries-might-show-us-many-people-can-avoid-going-under-the-knife-135325">The coronavirus ban on elective surgeries might show us many people can avoid going under the knife</a>
</strong>
</em>
</p>
<hr>
<p>One of the challenges for policymakers in the past in controlling low-value care has been <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30947-3/fulltext">difficulty in ratcheting down supply</a> by reducing or redirecting a hospital’s surgical capacity and staff. </p>
<p>In many ways, the COVID-19 response has done this for them. After the pandemic, we can reassess and reorient to high-value care.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/328248/original/file-20200416-140711-qfur1o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/328248/original/file-20200416-140711-qfur1o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/328248/original/file-20200416-140711-qfur1o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/328248/original/file-20200416-140711-qfur1o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/328248/original/file-20200416-140711-qfur1o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/328248/original/file-20200416-140711-qfur1o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/328248/original/file-20200416-140711-qfur1o.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">Some people will need catch-up surgeries after the pandemic, but some won’t.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/recovery-room-beds-comfortable-medical-interior-1406833052">Shutterstock</a></span>
</figcaption>
</figure>
<p>This does not necessarily mean reducing capacity. Some people aren’t currently getting the care they need. When the tap comes back on, this unmet backlog of care must be performed. </p>
<p>But this needn’t detract from a focused effort to keep the low-value care from re-emerging. The last thing we need is for low-value care to take the place of high-value care that has been delayed because of the COVID-19 response.</p>
<h2>So how do you do it?</h2>
<p>Australia should take three immediate steps to ensure we don’t return to the bad old days of open slather. </p>
<p>First, <a href="https://grattan.edu.au/report/questionable-care-avoiding-ineffective-treatment/">states should start reporting the rates of low-value care</a>, using established measures. This reporting should identify every relevant hospital – public and private – and it should be retrospective, showing rates for the past few years. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australians-are-undergoing-unnecessary-surgery-heres-what-we-can-do-about-it-46089">Australians are undergoing unnecessary surgery – here's what we can do about it</a>
</strong>
</em>
</p>
<hr>
<p>Second, states should require all public hospitals to take steps to limit low-value care – and hospitals that don’t comply should be called to account. </p>
<p>States have the insights and data necessary to do this. </p>
<p>Hospital strategies might include requiring a second opinion from another specialist before a procedure identified as low-value care is scheduled for surgery, or a retrospective review of decisions to perform such surgery.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/328249/original/file-20200416-140706-1yhzqyn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/328249/original/file-20200416-140706-1yhzqyn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/328249/original/file-20200416-140706-1yhzqyn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/328249/original/file-20200416-140706-1yhzqyn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/328249/original/file-20200416-140706-1yhzqyn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/328249/original/file-20200416-140706-1yhzqyn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/328249/original/file-20200416-140706-1yhzqyn.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">Hospitals could require second opinions before scheduling low-value procedures.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/many-people-waiting-room-see-doctor-778331905">Shutterstock</a></span>
</figcaption>
</figure>
<p>In the post-pandemic world, states should also consolidate elective surgery, so the number of centres performing elective procedures in metropolitan areas is reduced, with decision-making tools to highlight downsides of low-value care and the alternatives. </p>
<p>Third, private insurers know low-value care is provided in private hospitals, but currently have fewer levers at their disposal to reduce such care. The Commonwealth government should legislate to empower funds to address this issue. Given the Commonwealth government is providing financial support to the private hospitals during their downturn, perhaps a requirement should be that they work with the insurers and Medicare to police the re-emergence of low-value care. </p>
<p>It would be a dreadful shame to waste this unprecedented opportunity, and revert to the old status quo of low- and no-value care.</p><img src="https://counter.theconversation.com/content/136259/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adam Elshaug receives sitting fees from the Australian government as a member of the Medicare Benefits Schedule (MBS) Review Taskforce and as an advisor to Cancer Australia. He is a Board Member of the NSW Bureau of Health Information (BHI), and has consulted to provide low-value care related analyses and advice to the Australian Department of Veterans Affairs, Private Healthcare Australia, and the NSW, Queensland, Victoria and South Australia state health departments. He holds a HCF Research Foundation Professorial Fellowship which is paid to The University of Sydney and is a Chief Investigator on NHMRC grants.</span></em></p><p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities, as disclosed on its website. </span></em></p>Elective surgeries have been halted as part of the health system’s response to coronavirus. But many are unnecessary and shouldn’t be rescheduled after the pandemic ends.Adam Elshaug, HCF Research Foundation Professorial Fellow, Professor in Health Policy and Co-Director, Menzies Centre for Health Policy, University of SydneyStephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1352072020-03-31T06:09:21Z2020-03-31T06:09:21ZFederal government gets private hospital resources for COVID-19 fight in exchange for funding support<p>Private hospitals will be on the frontline in the coronavirus battle, under an arrangement with the federal government that makes available the sector’s more than 30,000 beds and 105,000 workforce, including more than 57,000 nursing staff.</p>
<p>The government will offer agreements to Australia’s 657 private and not-for-profit hospitals “to ensure their viability, in return for maintenance and capacity” during the COVID-19 crisis. </p>
<p>The agreement makes available more resources to meet the virus crisis, preserves the private hospital workforce, and is designed to allow a speedy resumption of non-urgent elective surgery and other normal activity when the crisis has passed.</p>
<p>The states will complete “private hospital COVID-19 partnership agreements”, with the Commonwealth paying half the cost.</p>
<p>“In an unprecedented move, private hospitals, including both overnight and day hospitals, will integrate with state and territory health systems in the COVID-19 response,” the government said in a Tuesday statement.</p>
<p>These hospitals “will be required to make infrastructure, essential equipment (including ventilators), supplies (including personal protective equipment), workforce and additional resources fully available to the state and territory hospital system or the Australian government”.</p>
<p>Private hospitals will support the COVID-19 response through:</p>
<ul>
<li><p>Hospital services for public patients – both positive and negative for COVID 19</p></li>
<li><p>Category 1 (urgent) elective surgery</p></li>
<li><p>Use of wards and theatres to expand ICU capacity</p></li>
<li><p>Accommodation for quarantine and isolation cases where necessary, and safety procedures and training are in place, including:</p>
<ul>
<li>Cruise and flight COVID-19 passengers</li>
<li>Quarantine of vulnerable members of the community</li>
<li>Isolation of infected vulnerable COVID-19 patients.</li>
</ul></li>
</ul>
<p>The cost of the move is estimated at $1.3 billion.</p>
<p>Last week the government announced a ban on non-urgent elective surgery. While this freed up beds and staff, it would also strip private hospitals of core income and threaten the collapse of some hospitals without government action.</p>
<p>Health Minister Greg Hunt said the agreement dramatically expanded the capacity of the Australian hospitals system to deal with COVID-19, at the same time as the curve of new cases showed early signs of being flattened.</p>
<p>The private hospitals “are available as an extension now of the public hospital system in Australia. So, whilst we’re not taking ownership, we have struck a partnership, where in return for the state agreements and the commonwealth guarantee, they will be fully integrated within the public hospital system”.</p>
<p>Hunt said the $1.3 billion estimated cost was not capped. “If more is required, more will be provided. If it turns out that it’s not that expensive, then those funds will be available for other activities. That takes our total additional investment to over $5.4 billion within the health sector.”</p>
<p>In a letter to private hospital providers, Hunt stressed: “A fundamental principle of this agreement is that it contributes towards to your ongoing viability, not profits or loan/debt repayments”. </p>
<p>Commonwealth deputy chief medical officer, Nick Coatsworth said intense efforts were being made to ramp up rapidly the number of ventilators.</p>
<p>He said there were some 2,200 ventilated intensive care beds in Australia. Currently just over 20 were being used for COVID-19 patients.</p>
<p>With immediate expansion, including repurposing and use of the private sector, this could be increased to 4,400.</p>
<p>“Our target capacity for ventilated intensive care beds in Australia currently stands at 7,500.</p>
<p>"We are working around the clock to procure ventilators,” he said. “Locally, we will have 500 intensive care ventilators fabricated by ResMed, backed up by 5,000 non-invasive ventilators, with full delivery expected by the end of April.”</p>
<p>The Australian Healthcare and Hospitals Association welcomed the “ground-breaking agreement” with private hospitals for ensuring both the best use of resources and the stability of the health system for the future. </p>
<p>The Australian tally of cases as of Tuesday afternoon was 4557, with 19 deaths; 244,000 tests had been completed.</p><img src="https://counter.theconversation.com/content/135207/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michelle Grattan 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>Private hospitals will be on the frontline in the coronavirus battle, under an arrangement with the federal government that makes available the sector’s more than 30,000 beds and 105,000 workforce.Michelle Grattan, Professorial Fellow, University of CanberraLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1283112019-12-10T19:05:12Z2019-12-10T19:05:12ZPrivate health premium increases might be the lowest in years, but that doesn’t mean they’re justified<figure><img src="https://images.theconversation.com/files/306011/original/file-20191210-95120-1rbv0mj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Those facing large price increases might drop or downgrade their cover.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-stressed-caucasian-couple-facing-financials-556308208?src=-1-5&studio=1">Wayhome studio/Shutterstock</a></span></figcaption></figure><p>Every year private health insurers raise premiums and every year we rue the hit to our hip pocket. This cycle is heavily regulated: insurers apply to the health minister who must approve premium hikes unless deemed contrary to the public interest. Premiums then change on April 1. </p>
<p>This time the federal health minister, Greg Hunt, has managed to keep <a href="https://www.greghunt.com.au/the-lowest-private-health-insurance-premium-change-in-19-years/">average premium growth to 2.92%</a> – the lowest in 19 years. This news comes two weeks after he <a href="https://www.canberratimes.com.au/story/6507690/hunt-rejects-health-premium-rise-paper/?cs=14231">rejected an industry proposal</a> to increase premiums by 3.5%. </p>
<p>While the government celebrates this apparently modest price rise, consumers are right to point out that premium growth continues to outstrip inflation and wage growth. How do insurers justify this?</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/premiums-up-rebates-down-and-a-new-tiered-system-what-the-private-health-insurance-changes-mean-114086">Premiums up, rebates down, and a new tiered system – what the private health insurance changes mean</a>
</strong>
</em>
</p>
<hr>
<h2>The case for higher premiums</h2>
<p>Australians have come to expect that come April 1 each year, their private health insurance costs will go up – often by a lot. </p>
<p>These increases have been substantially more than wage growth or inflation. Between 2011 and 2019, the <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/privatehealth-average-premium-round">cumulative growth</a> in nominal premiums (before rebates) was 49%. Over the same period <a href="https://www.abs.gov.au/ausstats/abs@.nsf/mf/6345.0">wages grew</a> by 21% and <a href="https://www.abs.gov.au/ausstats/abs@.nsf/mf/6401.0">CPI</a> by 16%. </p>
<p><iframe id="Lke7E" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/Lke7E/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Insurers have justified the growth in premiums by pointing out that benefits – the money private health insurers pay out when we go to hospital or have treatment – have also grown substantially. </p>
<p><a href="https://www.apra.gov.au/operations-of-private-health-insurers-annual-report">Benefits grew</a> on average 5.3% per year between 2014-2019. However, while earlier this decade <a href="https://theconversation.com/can-private-health-insurers-justify-a-6-2-premium-increase-38390">benefit growth consistently outpaced premiums</a>, this is no longer the case. </p>
<p><iframe id="x33IQ" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/x33IQ/4/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Growth in benefits is due to both higher medical costs and more claims. In fact, <a href="https://www.apra.gov.au/operations-of-private-health-insurers-annual-report">benefits per service</a> have hardly changed since 2014 and have actually fallen for prostheses (such as hip and knee replacements), which highlights the importance of growth in number of claims.</p>
<p><iframe id="BMGXp" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/BMGXp/3/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Insurers are also facing growing cost pressure due to the exodus of young people from insurance and an ageing insurance pool. </p>
<p>Traditionally young people have cross-subsidised the higher expenses of older people, but increasingly they are deciding that private insurance is a bad deal. In the past 12 months, the number of people aged 20-34 with private hospital cover <a href="https://www.apra.gov.au/quarterly-private-health-insurance-statistics">has declined</a> by almost 50,000. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-do-you-stop-the-youth-exodus-from-private-health-insurance-cut-premiums-for-under-55s-128101">How do you stop the youth exodus from private health insurance? Cut premiums for under-55s</a>
</strong>
</em>
</p>
<hr>
<h2>Are insurers’ profits too high?</h2>
<p>Insurers can point out that their profit margins are not unusually high compared to other forms of insurance. Figures from the <a href="https://www.apra.gov.au/quarterly-general-insurance-statistics">Australian Prudential Regulation Authority show</a> that in 2019 after-tax profits were 9.5% of premium revenue for general insurers. Meanwhile, after-tax profits for private health insurers were 5.6% (6.4% for for-profit funds).</p>
<p>Insurers can also point out that their net margins and benefits-to-premiums revenue ratios have been relatively stable over the past decade. Against this, growth in premiums has mostly acted to sustain profit margins rather than extend them.</p>
<p>But does this really matter for assessing price hikes? While shareholders would like to maintain the margins they’re accustomed to, there’s nothing intrinsically meaningful about historical figures. </p>
<p>The profits in one sector also don’t entitle insurers to the same profit in a different sector. </p>
<p>Ultimately, it’s hard to know what the “right” level of profit is. For now, private health insurance remains a relatively profitable industry.</p>
<h2>What will the price increase mean for you?</h2>
<p>Forty-four percent of Australians <a href="https://www.apra.gov.au/sites/default/files/Quarterly%20Private%20Health%20Insurance%20Statistics%20September%202019.pdf">have private hospital cover</a> and 53% have general treatment cover for things like dental and optical. For these Australians, the <a href="https://www.greghunt.com.au/the-lowest-private-health-insurance-premium-change-in-19-years/">health minister estimates</a> singles will pay an average of A$35 more per year (A$0.68 per week) and families A$103 more per year (A$1.99 per week).</p>
<p>It’s important to recognise that the 2.92% figure is a <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/0B815BFEB8EDECA7CA257BF000195929/$File/Premium-Round-Individual-Insurer-Average-Premium-Increases%E2%80%931997-to-2020.pdf">weighted industry average</a>. Some policies will increase by more (and less) than 2.92%. You will find out by how much your plan is increasing early next year. </p>
<p>Those facing large price increases might downgrade their cover and some may drop it altogether. If healthier people drop out of insurance, that will put upward pressure on premiums in the future.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/306014/original/file-20191210-95149-m0va2b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/306014/original/file-20191210-95149-m0va2b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/306014/original/file-20191210-95149-m0va2b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/306014/original/file-20191210-95149-m0va2b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/306014/original/file-20191210-95149-m0va2b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/306014/original/file-20191210-95149-m0va2b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/306014/original/file-20191210-95149-m0va2b.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">Australia’s private health insurance system relies on young people who don’t use their insurance to subsidise older Australians who do.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/fit-people-jogging-on-treadmills-gym-329554319">wavebreakmedia/Shutterstock</a></span>
</figcaption>
</figure>
<h2>So, is the 2020 premium increase justified?</h2>
<p>With the information at hand, 2.92% seems reasonable by historical standards. Growth in benefits has been declining since 2017 and this should flow to premiums.</p>
<p>Going forward, the government will need to do more than crack down on premium-setting if it wants to arrest growing costs. The biggest pressures are from rising hospital and medical fees and an ageing insurance pool. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/greedy-doctors-make-private-health-insurance-more-painful-heres-a-way-to-end-bill-shock-127227">Greedy doctors make private health insurance more painful – here's a way to end bill shock</a>
</strong>
</em>
</p>
<hr>
<p>Recent attempts to reduce costs by negotiating a better deal with medical device manufacturers was a good move, although <a href="https://www.privatehealthcareaustralia.org.au/medical-devices-companies-continue-to-drive-up-premiums-for-consumers/">insurers claim it failed to meaningfully lower their costs</a> because manufacturers increased the volume of devices sold. </p>
<p>Higher premium rebates for young people are more dubious since rebates are only <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1467-8462.2004.00327.x">cost-effective</a> if they cause lots of people to take up insurance who wouldn’t otherwise.</p>
<p>It’s been 21 years since the <a href="https://www.pc.gov.au/inquiries/completed/private-health-insurance">last Productivity Commission inquiry into the private health insurance industry</a>. Perhaps it’s time for another one.</p><img src="https://counter.theconversation.com/content/128311/count.gif" alt="The Conversation" width="1" height="1" />
<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>In April, private health insurance premiums will increase by an average of 2.92%. It’s the lowest rise in 19 years but still much higher than wages growth. And insurers still make a healthy profit.Nathan Kettlewell, Chancellor's Postdoctoral Research Fellow, Economics Discipline Group, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1263452019-11-07T05:30:31Z2019-11-07T05:30:31ZPrivate health insurers should start paying for hospital-type care at home<figure><img src="https://images.theconversation.com/files/300540/original/file-20191107-12474-r0q6zf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Having treatment at home is more convenient for patients.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/671185213?src=9a8830d7-2b96-41a2-9c10-cad4d2592fb0-1-38&size=huge_jpg">Photographee.eu/Shutterstock</a></span></figcaption></figure><p>In the past, when you needed chemotherapy or intravenous (in-the-vein) treatments such as antibiotics or hydration, you needed to be admitted to hospital. </p>
<p>These days, it’s possible to have such treatments in the comfort of your home, with nursing or other clinical supports. </p>
<p>Public hospital-in-the-home and other hospital-substitute programs are burgeoning in the public sector, including in <a href="https://www.mja.com.au/system/files/issues/193_10_151110/mon10237_fm.pdf">Victoria</a>, <a href="https://www.silverchain.org.au/wa/">Western Australia</a> and <a href="https://www.health.nsw.gov.au/Performance/Pages/HITH.aspx">New South Wales</a>. These programs now provide the equivalent of hundreds of hospital beds. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/from-triage-to-discharge-a-users-guide-to-navigating-hospitals-54658">From triage to discharge: a user's guide to navigating hospitals</a>
</strong>
</em>
</p>
<hr>
<p>Having treatment at home is more convenient for patients, reduces the demand on hospitals, and <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007491.pub2/abstract">cuts costs for the health system</a>.</p>
<p>But if you have private health insurance and want to access these services via a private hospital, it’s often not possible. This needs to change.</p>
<h2>What’s the problem?</h2>
<p>Private health insurers are tightly regulated. If you have a top “gold” package, for example, the insurer must pay for all hospital services that attract a government Medicare Benefits Schedule (MBS) payment, other than cosmetic surgery. </p>
<p>But insurers are currently <a href="https://www.health.gov.au/health-topics/private-health-insurance/about-private-health-insurance/how-does-private-health-insurance-work">not allowed to cover</a> care provided outside of hospitals, except in very limited circumstances.</p>
<p>Insurers <em>are</em> allowed to cover eligible home-based programs developed by private hospitals. But they get to decide on a case-by-case basis whether to cover these programs. And each insurer makes a separate decision for each program.</p>
<p>This means private hospitals must negotiate with each private health insurer for each separate program, for each contract period. This makes it almost impossible for private hospitals to develop sustainable business cases for their programs. </p>
<p>The upshot is patients often miss out on the convenience of having hospital-type services in their home, and instead may face prolonged hospital stays. </p>
<p>The red tape needs to be untangled to make it easier for private hospitals and doctors to run these programs and for insurers to pay for them. </p>
<h2>What kind of care can you get at home?</h2>
<p>Few hospital-type services are delivered at home under the current system for privately insured patients: they account for about <a href="https://www.apra.gov.au/quarterly-private-health-insurance-statistics">4% of hospital treatments paid in 2018-19</a>.</p>
<p><a href="https://www.cabrini.com.au/patients-and-families/services/directory/hospital-in-the-home">Common hospital-type treatments</a> in the home include IV therapy and wound care. </p>
<p>A number of insurers are conducting pilot programs for out-of-hospital rehabilitation after strokes, <a href="https://www.medibank.com.au/livebetter/my-medibank/using-your-cover/rehab-in-the-home/">joint replacements</a> or an accident; chemotherapy; kidney dialysis; and <a href="https://media.bupa.com.au/palliative-care-pilot-recognised/">palliative care</a>, so people can die more comfortably in their own homes.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/300580/original/file-20191107-12464-h9zryd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/300580/original/file-20191107-12464-h9zryd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/300580/original/file-20191107-12464-h9zryd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/300580/original/file-20191107-12464-h9zryd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/300580/original/file-20191107-12464-h9zryd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/300580/original/file-20191107-12464-h9zryd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/300580/original/file-20191107-12464-h9zryd.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">Pilot programs are underway to allow more people to die in their own homes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/637042651?src=a2a0948d-d998-442f-b83f-9cc19c94ede1-1-63&size=huge_jpg">Photographee.eu/Shutterstock</a></span>
</figcaption>
</figure>
<p>Untangling red tape would also allow private hospitals to offer more “<a href="https://www.bmj.com/content/358/bmj.j3702">prehabilitation</a>” programs to prepare people for elective surgery, and to offer <a href="https://www.mja.com.au/journal/2018/209/5/predictors-inpatient-rehabilitation-after-total-knee-replacement-analysis">rehabilitation programs in people’s homes</a> after surgery.</p>
<p>Theoretically, hospital-substitute programs at home could expand to other treatment areas such as obstetrics to have your baby at home. Or for <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/05EB674588C31EB7CA257E28001F1BBD/$File/Guidelines%20for%20Determining%20Benefits%202015%20Edition-Checked.pdf">mental health</a> treatment, which may be more efficiently provided outside hospital. </p>
<p>But legislative restrictions (designed to stop insurers covering general practice) have limited the expansion of these programs. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/waiting-for-better-care-why-australias-hospitals-and-health-care-are-failing-104862">Waiting for better care: why Australia’s hospitals and health care are failing</a>
</strong>
</em>
</p>
<hr>
<h2>How should the system work?</h2>
<p>Regulation should support people’s access to the most efficient form of care. And private hospitals should have more certainty about how they’ll be reimbursed when they invest in alternatives to hospital inpatient care. </p>
<p>Rather than each insurer deciding whether they should fund good programs, the independent body which assesses and approves the public-sector equivalent of home-based care – the <a href="https://www.ihpa.gov.au/">Independent Hospital Pricing Authority</a> – should do the same for the private sector. </p>
<p>If a program has been approved by the authority, then private health insurers should be required to pay for it.</p>
<p>Specialist doctors, such as oncologists, should also be able to establish hospital substitute programs and have them approved for funding by private health insurers.</p>
<p>All of this is about improving quality and access to care, while at the same time reducing costs. It should be easier for private health insurers to pay for better alternatives to hospital care, where they can deliver the same treatment with the same or better outcomes, <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007491.pub2/abstract">but at a lower cost</a>. </p>
<p>It is also about providing good alternatives to private hospital care, increasing competition in the health system, and reducing the number of unnecessary hospital admissions. </p>
<p>There are big opportunities for system-wide efficiencies in the private sector by shifting care from inpatient to outpatient settings – particularly for rehabilitation, psychiatric care, <a href="https://www.asrs.org/patients/retinal-diseases/33/intravitreal-injections">eye injections</a> for retinal conditions, and outpatient <a href="https://www.veinhealth.com.au/ambulatory-phlebectomy/">vein surgery</a>. </p>
<p>The public sector has already expanded its alternatives to hospital inpatient care. It’s time for the private system to do the same. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/do-you-really-need-private-health-insurance-heres-what-you-need-to-know-before-deciding-93661">Do you really need private health insurance? Here's what you need to know before deciding</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/126345/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities, as disclosed on its website.. </span></em></p>Patients often want the option to be treated at home rather than being admitted to hospital. But it’s much less likely to happen if you’re a private patient.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1111712019-02-27T19:16:48Z2019-02-27T19:16:48ZIs it time to ditch the private health insurance rebate? It’s a question Labor can’t ignore<figure><img src="https://images.theconversation.com/files/261331/original/file-20190227-150721-1dc4i0r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Premium subsidies encourage Australians to take out and keep private health insurance. </span> </figcaption></figure><p><em>This is part of a major series called Advancing Australia, in which leading academics examine the key issues facing Australia in the lead-up to the 2019 federal election and beyond. Read the other pieces in the series <a href="https://theconversation.com/au/topics/advancing-australia-66135">here</a>.</em></p>
<hr>
<p>This election campaign, Labor’s health focus is expected to be on Medicare, which it regards as one of its defining achievements. But with <a href="https://www.apra.gov.au/publications/private-health-insurance-membership-and-coverage">almost half the population</a> covered by private health insurance, Labor needs to tread carefully on this vexed topic. </p>
<p>Government subsidies for private health insurance premiums <a href="https://www.abc.net.au/news/2018-01-30/private-health-insurance-too-expensive-and-excludes-too-much/9374920">cost over A$6 billion a year</a>. Is it time to scrap the rebate and redirect these funds elsewhere in the health system?</p>
<p>If Labor sees private health insurance as a system that provides unnecessary extravagances that Medicare won’t cover, it can’t justify this type of subsidy.</p>
<p>But picking a fight with the private health insurance industry would be politically foolhardy. And families have factored the subsidies into their budgets, so cutting or eliminating the subsidies would put further pressure on family finances at a time of wage stagnation. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/do-you-really-need-private-health-insurance-heres-what-you-need-to-know-before-deciding-93661">Do you really need private health insurance? Here's what you need to know before deciding</a>
</strong>
</em>
</p>
<hr>
<p>We’re unlikely to see much of a discussion about private health insurance during the election campaign. But the party that wins government must commit to reforming the ailing private health insurance system. </p>
<h2>How did we get here?</h2>
<p>Private health insurance has been a contested policy zone for more than 50 years. </p>
<p>Gough Whitlam prompted a bitter debate over whether government health insurance should be for everyone (universal) or just for the poor (residual), when in 1968 he <a href="https://onlinelibrary.wiley.com/doi/abs/10.5694/j.1326-5377.1968.tb83536.x">committed Labor to a universal scheme</a> to replace the then residual model. The new universal model eventually became Medibank in 1975, then Medicare in 1984. </p>
<p>It wasn’t until the 1996 election that then opposition leader John Howard formally conceded defeat on this issue, acknowledging that Medicare should be for all. However, Liberal governments keep returning to “residual” rhetoric, <a href="https://www.sbs.com.au/news/too-many-free-medicare-services-dutton">arguing wealthy people should pay directly for health care</a> rather than use the universal scheme, Medicare.</p>
<p>After winning the 1996 election, Howard opened a second front in the health-care war by <a href="https://theconversation.com/private-health-insurance-carrot-and-stick-reforms-have-failed-heres-why-38501">reinstituting government subsidies for private health insurance</a>. </p>
<p>The cost of the first subsidy scheme – known as the Private Health Insurance Incentive Scheme – was estimated at A$600 million a year. Two decades later, the private health insurance subsidy has increased ten-fold to <a href="https://theconversation.com/private-health-insurance-rebates-dont-serve-their-purpose-lets-talk-about-scrapping-them-91061">more than A$6 billion a year</a>.</p>
<h2>Getting people to sign up and stay</h2>
<p>Liberal governments offer <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/(SICI)1099-1050(199912)8:8%3C653::AID-HEC491%3E3.0.CO;2-I">carrots to encourage people to take out insurance</a> – subsidies for premiums – but also use two sticks to penalise people for not taking out insurance. The sticks have proved to be <a href="http://www.publish.csiro.au/AH/AH020033">more effective than the carrots</a> in increasing insurance enrolment.</p>
<p>The first stick penalises the rich if they don’t have private health insurance. It is based on the “residual” ideology, that those who can afford to pay their own way should take out private health insurance and not use public hospitals. This stick takes the form of a <a href="https://www.ato.gov.au/individuals/medicare-levy/medicare-levy-surcharge/">Medicare Levy surcharge</a>, starting at 1% of income to be paid by singles who earn more than A$90,000 a year, or families on more than A$180,000 a year. People who have private health insurance are exempt from the surcharge.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/private-health-insurance-premium-increases-explained-in-14-charts-92825">Private health insurance premium increases explained in 14 charts</a>
</strong>
</em>
</p>
<hr>
<p>The second stick penalises people who do not take out private health insurance before turning 31. They have to pay higher premiums if they join later in life. When introduced in 2000 this scheme – known as <a href="https://www.privatehealth.gov.au/healthinsurance/incentivessurcharges/lifetimehealthcover.htm">Lifetime Healthcover</a> – increased coverage from about <a href="https://theconversation.com/private-health-insurance-premium-increases-explained-in-14-charts-92825">30% to around 45%</a> of the population.</p>
<h2>What is private health for?</h2>
<p>Neither side of politics has confronted the fundamental question: what is the role of private health care and private health insurance, given we have universal health coverage?</p>
<p>Private health insurance can complement universal health insurance, providing insurance for services not covered by Medicare. Dental insurance is a good example. </p>
<p>Private health insurance can also be a substitute, where it overlaps with or replaces the public scheme, such as insurance for private hospital care for hip replacements. <a href="https://www.cambridge.org/core/journals/health-economics-policy-and-law/article/expanding-the-breadth-of-medicare-learning-from-australia/7D92551D6E3E393AC27123D14B7615C9">More than half of all hip replacements</a> are done in private hospitals. </p>
<p>The Liberal approach is simple: private health insurance is both an essential substitute for the universal public hospital system (“<a href="https://www.privatehealthcareaustralia.org.au/phi-rebate-keeps-pressure-off-public-hospitals-2/">it takes pressure off the public hospital system</a>”) and a complement (“<a href="https://theconversation.com/explainer-why-do-australians-have-private-health-insurance-38788">it gives people choice of doctor</a>”).</p>
<p>Labor approaches private health insurance a bit like one might approach a dead cat on the table – as an issue that has to be dealt with, but that everybody wishes would just go away.</p>
<p>But private health insurance won’t go away. If Labor sees it solely as a complement, providing unnecessary extravagances not covered by Medicare, then the argument for any public subsidy is weak. </p>
<p>But if Labor sees private care primarily as a substitute, then the A$6 billion of subsidy to private care through the rebate may be better value for money than further support for public hospitals. If that is the case, Labor will have to confront the issue of whether to continue some combination of carrots and sticks, and what can be done to make the industry more efficient.</p>
<h2>Time for real reform</h2>
<p>Private health insurance premiums have risen dramatically, faster than average weekly earnings, as have consumer complaints.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/258620/original/file-20190213-90469-p6d67u.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/258620/original/file-20190213-90469-p6d67u.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/258620/original/file-20190213-90469-p6d67u.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=543&fit=crop&dpr=1 600w, https://images.theconversation.com/files/258620/original/file-20190213-90469-p6d67u.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=543&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/258620/original/file-20190213-90469-p6d67u.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=543&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/258620/original/file-20190213-90469-p6d67u.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=682&fit=crop&dpr=1 754w, https://images.theconversation.com/files/258620/original/file-20190213-90469-p6d67u.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=682&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/258620/original/file-20190213-90469-p6d67u.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=682&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p>Labor is seeking to exploit public outrage at high private health insurance premiums by <a href="https://www.smh.com.au/business/consumer-affairs/shorten-s-private-health-premium-cap-bad-policy-or-circuit-breaker-20180802-p4zv6w.html">promising to establish a Productivity Commission review</a> into the sector. </p>
<p>In the meantime, Labor would <a href="https://theconversation.com/labors-2-cap-on-private-health-insurance-premium-rises-wont-fix-affordability-91232">freeze private health insurance premium increases</a> – in effect, kicking the policy can two years down the road.</p>
<p>Whichever party wins the election, it ought to revisit our nation’s history with failing industries. Over recent decades we have learnt that propping up industries in the face of consumers turning away from their products is not a long-term proposition. </p>
<p>Private health insurance is no car industry, but it’s not a sunrise industry either. Yet it receives a greater subsidy than manufacturing at its <a href="https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/rp9900/2000RP07">subsidised peak</a> at the end of the 1960s. </p>
<p>The government has to decide why it’s subsidising the private health care industry. If it decides it doesn’t want to in future, it needs a carefully managed transition.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/private-health-insurance-rebates-dont-serve-their-purpose-lets-talk-about-scrapping-them-91061">Private health insurance rebates don't serve their purpose. Let's talk about scrapping them</a>
</strong>
</em>
</p>
<hr>
<p>Even if private care is seen primarily as a substitute for the public sector – and a way to take some demand off – subsidies for private care may be counter-productive. </p>
<p>Doctors earn more for each hour worked in the private sector, which makes it <a href="https://www.sciencedirect.com/science/article/pii/S0168851013000766">harder for public hospitals to attract staff</a>. So subsidies may end up undermining access to care in the public system. </p>
<p>Australians feel pressured to take out private health insurance because of the sticks, but the product is only sustainable with its current level of coverage because of the carrots: the hefty public subsidies. Without the carrots and sticks, coverage would probably return to the <a href="https://theconversation.com/private-health-insurance-premium-increases-explained-in-14-charts-92825">pre-1996 levels</a> of around one-third of the population. </p>
<p>The incoming government should look at the effectiveness and efficiency of the carrots and sticks, whether consumers and taxpayers get value for money from private health insurance, and how to address rising out-of-pocket costs.</p><img src="https://counter.theconversation.com/content/111171/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities as disclosed on its website.</span></em></p>Subsidies for private health insurance premiums cost the government over A$6 billion a year. Is it time to scrap the rebate and redirect these funds elsewhere in the health system?Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1014622018-08-21T13:44:25Z2018-08-21T13:44:25ZInquiry sets out how parts of the private health care sector in South Africa can be fixed<figure><img src="https://images.theconversation.com/files/232462/original/file-20180817-165943-p5tvvc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>A <a href="http://www.compcom.co.za/healthcare-inquiry">Health Market Inquiry</a> into South Africa’s private health care sector has established that the market is dominated by a few players. In such an environment, non-competitive behaviour such as collusion and excessive pricing tends to <a href="https://theconversation.com/why-the-dominance-of-big-players-is-bad-for-south-africas-economy-92058">thrive</a>. These dominant firms withhold key information which leaves consumers disempowered and at the mercy of monopolistic enterprises.</p>
<p>South Africa’s medical schemes market reflects acute domination by a few players. A few examples illustrate this. Among a total of 22 medical schemes open to the public, one scheme, Discovery Health Medical Scheme, is home to 55% of all medical scheme beneficiaries. Among the administrators contracted by medical schemes to manage and administer medical insurance, two companies – Discovery Health and Medscheme – account for 76% of total gross contribution income. And as much as 83% of private hospital beds are owned by the three large hospital groups: Netcare, Mediclinic and Life.</p>
<p>On top of this a handful of big corporations have controlling stakes in the few players that dominate the private health care industry, with some individuals serving as directors on the boards of multiple companies. </p>
<p>The report argues that the lack of competitive pressure feeds high prices for medical goods and services. The situation is made worse by information asymmetry – customers know much less than the companies offering the services – which makes for uninformed consumers. </p>
<h2>Closing the gap</h2>
<p>The report makes recommendations to close this information gap under five broad themes:</p>
<p>Standard benefit packages: Medical schemes should be required to offer a similar standard benefit package. This will allow those purchasing medical insurance to make better informed choices based on value-for-money.
This should cover prescribed minimum benefits as well as cost-effective out-of-hospital care and primary and preventive health care.</p>
<p>In this way, consumers can easily compare the prices of the basic option offered by different schemes and make decisions based on value-for-money. The coverage offered under this package will be exempt from co-payments to medical schemes or additional billing by providers. </p>
<p>Reimbursement and pay for performance: Doctors and specialists are currently paid for every individual service provided to the patient on a reimbursement basis, called fee-for-service payment. This often results in overuse and over-prescription, known as supply-induced demand. The problem of supply-induced demand is worsened by the fact that the prices of medical services are unregulated.</p>
<p>This needs to change and alternative ways to reimburse doctors and specialists needs to be found that links the service they offer to how they perform. </p>
<p>Medical brokers: The position and role of brokers in the South African medical aid industry has been <a href="https://theconversation.com/why-south-africa-needs-to-discipline-the-private-healthcare-industry-100410">precarious</a>. For one, its not clear whose side they’re on as they are often paid by and working for only one specific scheme which dilutes their objectivity.</p>
<p>And the fact that the majority of consumers are allocated a broker by default, through a practice called opt out, is highly problematic.</p>
<p>The report recommends that the opt out practice should be changed to one that allows people to opt in. Scheme members will be able to exercise their choice of making use of the services of a medical broker – or not – on an annual basis. </p>
<p>Clients without brokers will pay proportionally lower scheme membership fees. They will also be able to directly engage with medical schemes rather than through brokers, including applying for membership.</p>
<p>Disclosure of information: The report recommends that customers must be given far more information than is currently the case. This should include, for example, details on the costs of particular care. And, as a matter of course, service providers should declare their interests in facilities being used. For example, a service provider should provide the patient with information on their shareholding in the facility where the service is being provided. They must also declare their financial interest in any product they use, dispense or prescribe.</p>
<p>Another recommendation is that all fee-for-service tariffs should be published and displayed at each place where patients make contact with the health care system. This includes the consulting rooms of doctors and specialists as well as hospital reception areas. Other information of interest and value to the clients of private medical schemes should also be put in the public domain. This could include information on the results and value of adopting alternative methods to pay health care providers.</p>
<p>Information on administrative costs and income from broker fees should also be published by the Council for Medical Schemes on an annual basis.</p>
<p>Voice and participation: The report calls for consumer activism. This includes attendance by scheme members of their insurer’s Annual General Meeting. </p>
<p>The report also calls for activism by civil society organisations. These can make representations to the proposed forum responsible for setting fee-for-service tariffs.</p>
<h2>The long road ahead</h2>
<p>A number of factors will determine how fast, and how far, change takes place.</p>
<p>Certainly, the legislative changes needed to make it possible for the inquiry’s recommendations to be implemented will take time. And the success of many of the initiatives will ultimately depend on buy-in from medical schemes, scheme administrators, and medical practitioners. </p>
<p>Equally critical will be the capacity to effectively manage and to hold accountable new institutions – such as a Supply-Side Regulator – as proposed in the report.</p><img src="https://counter.theconversation.com/content/101462/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Frederik Booysen 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>Findings from South Africa’s Health Market Inquiry makes recommendations to close the information gap between service providers and consumers.Frederik Booysen, Professor of Economics: School of Economic and Business Sciences Frederik Booysen, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1015132018-08-19T19:49:14Z2018-08-19T19:49:14ZTo keep patients safe in hospitals, the accreditation system needs an overhaul<figure><img src="https://images.theconversation.com/files/232230/original/file-20180816-2894-1ik3tw5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rates of infection vary between hospitals, but these differences aren't picked up in the accreditation process.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1145401337?src=iEz4tI4VG8Dqg_569zAmBg-4-26&size=huge_jpg">Shutterstock</a></span></figcaption></figure><p>Once a year, inspectors visit hospitals across the country to assess their performance on a range of measures, from <a href="https://www.safetyandquality.gov.au/wp-content/uploads/2017/12/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf">medication safety to consumer engagement</a>. But it’s not a secret shopper-type scenario. Hospital staff have known for months when the inspectors will arrive and what they will be looking for. </p>
<p>It’s no wonder <a href="https://qualitysafety.bmj.com/content/25/9/716">doctors dismiss the process</a> as irrelevant or a waste of their time. But most concerning is the process doesn’t identify the key safety issues in hospitals, nor propose ways to address them. </p>
<p>Almost every significant safety failure in Australian hospitals in recent decades has happened in a hospital that had passed accreditation with flying colours. </p>
<p>Bundaberg Hospital passed accreditation, despite allowing <a href="https://books.google.com.au/books?id=mfx6iIDnBFAC&printsec=frontcover&dq=Sick+to+Death:+A+manipulative+surgeon+and+a+health+system+in+crisis+-+a+disaster+waiting+to+happen&hl=en&sa=X&ved=0ahUKEwjr7of3qvLcAhWEvLwKHW_LBhUQ6AEIKTAA#v=onepage&q=Sick%20to%20Death%3A%20A%20manipulative%20surgeon%20and%20a%20health%20system%20in%20crisis%20-%20a%20disaster%20waiting%20to%20happen&f=false">surgeon Jayant Patel (later dubbed Dr Death)</a> to continue practising after complaints from patients and staff about his competence.</p>
<p>Bacchus Marsh Hospital, where <a href="https://grattan.edu.au/news/lessons-from-bacchus-marsh/">seven seven babies died</a> after receiving sub-optimal care, had regularly passed accreditation. The hospital was about to get a new accreditation certificate when the story broke. </p>
<p>And Bankstown-Lidcombe Hospital in New South Wales, where a <a href="http://www.health.nsw.gov.au/news/Pages/20160827_00.aspx">gas mix-up</a> left one baby dead and another brain-damaged, was accredited.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/infections-complications-and-safety-breaches-why-patients-need-better-data-on-how-hospitals-compare-86748">Infections, complications and safety breaches: why patients need better data on how hospitals compare</a>
</strong>
</em>
</p>
<hr>
<p>A new <a href="https://grattan.edu.au/home/health/">Grattan Institute report</a> shows how accreditation needs to change. Australia’s one-size-fits-all system of assessing hospitals against centrally determined “standards” must be replaced with a system tailored to address the specific weaknesses of each hospital. </p>
<p>The report shows that a hospital’s performance in one specialty is unrelated to its performance in another – a hospital may have the lowest rate of surgical complications in orthopaedics, but the highest rate of medication complications in general medicine. </p>
<h2>One size fits all system</h2>
<p>Some 40 years ago, I <a href="https://primoa.library.unsw.edu.au/primo-explore/fulldisplay?docid=UNSW_ALMA21119360570001731&context=L&vid=UNSWS&lang=en_US&search_scope=SearchFirst&adaptor=Local%20Search%20Engine&tab=default_tab&query=any,contains,duckett%20accreditation&sortby=rank&offset=0">evaluated Australia’s relatively new hospital accreditation system</a> for my PhD. Back then, hospitals were expected to meet a set of standards. Inspectors visited a hospital to assess it against the standards. They produced a report, which remained secret. </p>
<p>An independent body would make an assessment of the report, and the assessment also remained secret. Then, in almost every case, the hospital was awarded “accreditation”.</p>
<p>Inexcusably, today the process remains the same (though we do have <a href="https://www.safetyandquality.gov.au/our-work/assessment-to-the-nsqhs-standards/nsqhs-standards-second-edition/">better standards</a> and a better report). No other part of Australia’s hospital system has been so immune from fundamental change over those 40 years.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/232244/original/file-20180816-2906-xreygy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/232244/original/file-20180816-2906-xreygy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/232244/original/file-20180816-2906-xreygy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/232244/original/file-20180816-2906-xreygy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/232244/original/file-20180816-2906-xreygy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=515&fit=crop&dpr=1 754w, https://images.theconversation.com/files/232244/original/file-20180816-2906-xreygy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=515&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/232244/original/file-20180816-2906-xreygy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=515&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">We need to know how individual departments in each hospital are tracking.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/karachi-pakistan-11292015-interior-empty-hospital-1148372999?src=nCyVKbbKxPamM7ARcR34Nw-1-74">Shutterstock</a></span>
</figcaption>
</figure>
<p>Back then it was <a href="https://www.jstor.org/stable/3763428">difficult to measure a hospital’s performance</a> on patient complications, and the quality of care. This was partly because we didn’t know whether a patient had a particular diagnosis when they were admitted to the hospital, or whether the diagnosis arose because of something that happened in hospital. </p>
<p>We couldn’t compare one hospital with another hospital, so we had to rely on independent qualitative judgements. </p>
<p>Not any more. Today we can <a href="https://www.mja.com.au/journal/2009/191/10/classification-hospital-acquired-diagnoses-use-routine-hospital-data">measure hospital complication rates</a> and other safety indicators to assess a hospital’s performance and compare them with others. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/hospitals-are-risky-places-but-some-are-better-than-others-91057">Hospitals are risky places – but some are better than others</a>
</strong>
</em>
</p>
<hr>
<p>The dangers of a one-size-fits-all accreditation system can be illustrated by considering infection control, which is one of the current national standards for hospitals. </p>
<p>Hospital-acquired infections are widespread – <a href="https://grattan.edu.au/report/all-complications-should-count-using-our-data-to-make-hospitals-safer/">more than one in every hundred patients contract one</a> – and cost the hospital system almost A$1 billion each year.</p>
<p>The accreditation visit to the hospital with Australia’s lowest hospital-acquired infection rate will look very similar to the visit to the hospital with the highest rate. The same information will be read, people in the same roles will be interviewed, and the same boxes about <a href="https://www.safetyandquality.gov.au/wp-content/uploads/2017/12/National-Safety-and-Quality-Health-Service-Standards-Guide-for-Hospitals.pdf">identifying the problems and training staff</a> will be ticked. </p>
<p>But the hospital with the worse infection record will have no way of learning from the best performer, and infection rates across the system will be unlikely to improve.</p>
<h2>Tailoring accreditation</h2>
<p>A new accreditation system needs to be tailored to each hospital’s situation. </p>
<p>All hospitals – public and private – should be given data about their complication rates and how they compare to other hospitals. The data provided to each hospital should be so specific that the hospital’s orthopaedic unit, for example, can compare its complication rates with its peers. </p>
<p>Hospitals and their clinical units should then develop plans to reduce their complications rates:</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/232243/original/file-20180816-2918-1sli12l.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/232243/original/file-20180816-2918-1sli12l.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/232243/original/file-20180816-2918-1sli12l.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=487&fit=crop&dpr=1 600w, https://images.theconversation.com/files/232243/original/file-20180816-2918-1sli12l.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=487&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/232243/original/file-20180816-2918-1sli12l.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=487&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/232243/original/file-20180816-2918-1sli12l.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=612&fit=crop&dpr=1 754w, https://images.theconversation.com/files/232243/original/file-20180816-2918-1sli12l.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=612&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/232243/original/file-20180816-2918-1sli12l.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=612&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 proposed new accreditation cycle would focus on enhancing the safety and quality of patient care.</span>
<span class="attribution"><span class="source">Grattan Institute</span></span>
</figcaption>
</figure>
<p>Under the plan, hospitals would no longer be spruced up for a scheduled, visit by accreditation inspectors every few years. Instead, surveyors would visit without notice. The surveyors would focus on providing feedback to the hospital on how it can strengthen its own safety processes.</p>
<p>After each visit, the survey report should be released publicly. That way, patients and their families and GPs could make better-informed decisions about which hospitals to go to. </p>
<p>The cycle of visit and report should be repeated every few years. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-you-should-avoid-hospitals-in-january-89857">Why you should avoid hospitals in January</a>
</strong>
</em>
</p>
<hr>
<p>This dramatic change to the way Australia’s hospitals are accredited cannot occur overnight. Data has to be provided to hospitals in <a href="https://grattan.edu.au/report/strengthening-safety-statistics/">an actionable form</a>, staff have to be trained in how to understand statistical variation and how to <a href="http://www.ihi.org/resources/Pages/Publications/ImprovementGuidePracticalApproachEnhancingOrganizationalPerformance.aspx">implement improvement strategies</a>, and the new model needs to be piloted and evaluated. </p>
<p>But the sooner we make the transition, the better we’ll be able to care for Australians who have to go into hospital.</p><img src="https://counter.theconversation.com/content/101513/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities as disclosed on its website. </span></em></p>Each year, inspectors visit Australian hospitals. But they’re less like secret shoppers who identify flaws, and more like guests of a carefully orchestrated performance. This needs to change.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1006972018-08-16T13:51:16Z2018-08-16T13:51:16ZMarket concentration is plaguing South Africa’s private health care market<figure><img src="https://images.theconversation.com/files/231911/original/file-20180814-2906-swdjqa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The preliminary findings of a recent inquiry into South Africa’s private <a href="http://www.compcom.co.za/healthcare-inquiry/">health care sector</a> shows worrying trends. Key among the inquiry’s revelations are high concentration levels in the market. </p>
<p>For example, the report shows that 70% of the open medical schemes market is controlled by two players – Discovery Health Medical Scheme and Bonitas. The market for restricted medical aid schemes is dominated by the Government Employees Medical Scheme, with a 47% market share. The medical scheme administrators market is controlled by three players, Discovery Health, MMI Holdings and Medscheme. These three have a 70% combined market share. </p>
<p>The situation is no better in the market for private hospitals. Three hospital groups – Netcare, Mediclinic and Life Healthcare – hold 83% of the national market. </p>
<p>The concentration problem in the private health care sector is further compounded by integration. Two of the largest medical scheme administrators, Discovery Health and MMI Holdings Limited, and one of the largest hospital groups, Mediclinic, have common ownership. </p>
<p>A market dominated by few players creates an environment in which collusion, abuse of dominance and other anti-competitive conduct <a href="https://theconversation.com/why-the-dominance-of-big-players-is-bad-for-south-africas-economy-92058">can thrive</a>. To remedy the problems identified by the inquiry, addressing the problem of concentration is key. This is because it’s the root cause of other problems affecting the sector.</p>
<p>But sadly there isn’t much that competition authorities can do. The Competition Act empowers competition authorities to take effective remedial actions in cases involving mergers, collusion and abuse of dominance. But not when it comes to concentration. This means under the current law the health care market inquiry won’t result in any effective remedial steps being taken.</p>
<p>But there’s hope. If amendments to the country’s <a href="https://pmg.org.za/call-for-comment/629/">competition law</a> are passed by parliament the law relating to market inquiries will be strengthened. The Bill will empower competition authorities to impose more radical remedies, such as divestiture, to address the problem of concentration. Divestiture would involve, for example, a dominant firm being ordered to sell or dispose of its shares or assets to free up the market.</p>
<h2>Can divestiture work?</h2>
<p>Divestiture can be a drastic and sometimes controversial remedy. Because of this there’s an acceptance that it be used sparingly and as a last resort. It works best when other remedies have failed. </p>
<p>That’s not to deny divestiture its place in competition law enforcement. </p>
<p>Divestiture orders have been part of competition law enforcement for almost 130 years dating back to 1890 when the world’s first competition statute, the Sherman Act, <a href="http://shodhganga.inflibnet.ac.in/bitstream/10603/100395/10/10_chapter%202.pdf">was passed in the US</a>. Ever since the US has used divestiture to prevent monopolies from happening as well as to loosen the unhealthy grip of one or few firms on the market. </p>
<p>In the 1911 <a href="https://supreme.justia.com/cases/federal/us/221/1/">world famous case</a> of Standard Oil Co of New Jersey v United States, the American Supreme Court ordered that Standard Oil be broken up into 34 independent corporations. Standard Oil had monopolised the entire American oil sector. </p>
<p>Another <a href="https://law.justia.com/cases/federal/appellate-courts/F2/148/416/1503668/">prominent case</a> in which the Supreme Court ordered divestiture is United States v Aluminium Company of America . Here the Supreme Court’s remarks about monopoly were more telling:</p>
<blockquote>
<p>Possession of unchallenged economic power invariably killed initiative and discouraged thrift.</p>
</blockquote>
<p>In United States v Columbia Steel Co, <a href="https://supreme.justia.com/cases/federal/us/334/495/">another case</a> of historic significance, the Supreme Court also ordered divestiture. The court found that monopoly was an “industrial menace”, because of the firm’s ability to create inequalities in relation to its competitors. Monopoly was also found to be a “social menace”, because of the firm’s ability to control prices. </p>
<p>Recently, in 2000, information technology giant, Microsoft, also received a divestiture order. In <a href="https://law.justia.com/cases/federal/district-courts/FSupp2/87/30/2307082/">that case</a>, United States v. Microsoft Corp, a Judge ruled that Microsoft established an unlawful monopoly and abused its dominance. The Judge ordered that Microsoft must be broken down into two separate units, one to produce computer operating systems and the other software components. </p>
<p>This decision was later overturned on appeal. But <a href="https://www.brookings.edu/wp-content/uploads/2016/06/05_microsoft_litan.pdf">some observers</a> still believe that divestiture was an appropriate remedy because where anti-competitive conduct is made possible by market power, divestiture may be a suitable remedy. </p>
<p>South Africa should follow the American example by using divestiture to free up concentrated markets when circumstances require.</p><img src="https://counter.theconversation.com/content/100697/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Phumudzo S. Munyai 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>Domination of key South African markets by a few players, as displayed in the healthcare market inquiry, may require authorities to consider breaking up monopolies.Phumudzo S. Munyai, Associate Professor, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/936612018-03-27T19:11:36Z2018-03-27T19:11:36ZDo you really need private health insurance? Here’s what you need to know before deciding<figure><img src="https://images.theconversation.com/files/212124/original/file-20180327-188604-1reew9a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some people choose private health insurance for shorter wait times.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-male-patient-modern-hospital-1043985610?src=nCyVKbbKxPamM7ARcR34Nw-1-89">l i g h t p o e t/Shutterstock</a></span></figcaption></figure><p>Every year at the end of March and early in April, the <a href="http://www.apra.gov.au/PHI/Publications/Pages/Quarterly-Statistics.aspx">11 million Australians</a> who have private health insurance receive notification that premiums are increasing. </p>
<p>Premiums will increase by an average of 3.95% from April 1 and will <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/privatehealth-average-premium-round">vary with the insurer</a> and the product. The increase is lower than previous years but still higher than any wage growth, leaving consumers wondering if they should give it up or downgrade to save money.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/private-health-insurance-premium-increases-explained-in-14-charts-92825">Private health insurance premium increases explained in 14 charts</a>
</strong>
</em>
</p>
<hr>
<h2>Why go private?</h2>
<p>Australia has a universal health care system, Medicare. Health care is available to all and is financed, in part, through a <a href="https://www.ato.gov.au/Individuals/Medicare-levy/">2% tax on our wages</a> (the Medicare levy). Access to general practitioners and public hospitals are just some of the benefits. </p>
<p>The Commonwealth government <a href="https://www.privatehealth.gov.au/healthinsurance/incentivessurcharges/">encourages Australians to have</a> private health insurance. It imposes penalties for not taking it out (paying more income tax: the <a href="https://www.ato.gov.au/Individuals/Medicare-levy/Medicare-levy-surcharge/">Medicare levy surcharge</a>) and offers incentives for those who do (rebates on premiums). </p>
<p>Some 45.8% of Australians have private health insurance, a rise <a href="http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4815.0.55.001Main+Features12001">from 31% in 1999</a>. </p>
<p>Australians have different reasons for taking out private health insurance. For some, it makes financial sense to take out policies to avoid paying the Medicare levy surcharge.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-why-do-australians-have-private-health-insurance-38788">Explainer: why do Australians have private health insurance?</a>
</strong>
</em>
</p>
<hr>
<p>Others choose to take out policies to avoid waiting times for elective treatment (predominantly surgery); to choose their own specialist or hospital; or to have the option of a private room, better food or more attractive facilities. </p>
<p>Some people perceive that private health insurance will give them access to better care in the private system. Many are fearful they won’t get the services they need in the public system. </p>
<h2>Shorter waits than the public system</h2>
<p>A universal health system is based on people with the most clinical need gaining access to the services required. </p>
<p>Most emergency treatment is provided in public hospitals. The case is different for “non-urgent” or elective surgery, with patients encouraged to use their private health insurance, mainly because of waiting times for such surgery in the public system. </p>
<p><a href="https://www.aihw.gov.au/reports/hospitals/ahs-2015-16-admitted-patient-care/contents/table-of-contents">Elective surgery waiting times</a> for public hospitals vary according to whether patients are publicly or privately funded. In <a href="https://www.aihw.gov.au/getmedia/3e1d7d7e-26d9-44fb-8549-aa30ccff100a/20742.pdf.aspx?inline=true">2015-2016</a>, the median waiting time (the time within which 50% of all patients are admitted) was 42 days for public patients, 20 days for patients who used their private health insurance to fund their admission, and 16 days for those who self-funded their treatment. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/212127/original/file-20180327-188619-c0s64a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/212127/original/file-20180327-188619-c0s64a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=419&fit=crop&dpr=1 600w, https://images.theconversation.com/files/212127/original/file-20180327-188619-c0s64a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=419&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/212127/original/file-20180327-188619-c0s64a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=419&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/212127/original/file-20180327-188619-c0s64a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=526&fit=crop&dpr=1 754w, https://images.theconversation.com/files/212127/original/file-20180327-188619-c0s64a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=526&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/212127/original/file-20180327-188619-c0s64a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=526&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Private patients often have shorter waits.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1053274676?src=QDXmElqtgzA9ILzHXyZmJw-1-14&size=medium_jpg">Iakov Filimonov/Shutterstock</a></span>
</figcaption>
</figure>
<p>Bear in mind, however, that waiting times vary according to clinical urgency. <a href="https://www.aihw.gov.au/getmedia/a7235c2d-3c90-4194-9fa1-b16edf7ff1f0/aihw-hse-197.pdf.aspx?inline=true">In 2016-17</a> in New South Wales, 98% of public patients were admitted within the clinically recommended time frame.</p>
<p>Differences in waiting times also vary according to the type of procedure. In <a href="https://www.aihw.gov.au/getmedia/3e1d7d7e-26d9-44fb-8549-aa30ccff100a/20742.pdf.aspx?inline=true">2015-2016</a>, cardiothoracic (heart) surgery had a median waiting time of 18 days for public patients and 16 days for all other patients. In contrast, the median wait for public patients needing total knee replacement was 203 days, and 67 days for all other patients.</p>
<h2>The question of choice</h2>
<p>Choice of provider is a leading reason people take out private health insurance. </p>
<p>The idea that consumers should have choice in the services they receive has been promoted by government and private health insurance companies for some years, with great success. Many consumers now believe that more choice is better and private health insurance is an “enabler of choice”. </p>
<p>But do people really have choice? Choice is not equally distributed, and not everyone with private health insurance gets the choices they desire. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/private-health-insurance-and-the-illusion-of-choice-10985">Private health insurance and the illusion of choice</a>
</strong>
</em>
</p>
<hr>
<p>Private health insurers reserve the right to restrict benefits, or provide maximum benefits for using their “preferred providers”. This, in fact, limits the choices consumers can make. </p>
<p>A recent example of this is the <a href="https://www.choice.com.au/money/insurance/health/articles/bupa-cuts-health-insurance-benefits-010318">announcement from Bupa</a> that, from August 1, members will face higher out-of-pocket costs in private hospitals that don’t have a special relationship with the company, and some procedures will be excluded from particular policies. </p>
<h2>Finding the best policy</h2>
<p>If you decide to keep your private health insurance, make sure you’re getting the best deal on a policy that’s right for you. Shop around for a policy that meets your needs. </p>
<p>Take note of what is excluded. If you are thinking about starting a family, you may want to look at whether obstetrics care is covered. For those who are older, inclusions such as hip replacements and cataract removal may be more important. </p>
<p>The Australian government website <a href="https://www.privatehealth.gov.au">PrivateHealth.gov.au</a> or the <a href="https://www.choice.com.au/money/insurance/health/compare">Choice health insurance finder</a> are good places to start. These include all registered health funds in Australia and allow you to compare what is covered in each policy. </p>
<p>Other “free” comparison sites may compare only some health funds and policies, or earn a <a href="https://www.choice.com.au/money/insurance/insurance-advice/articles/insurance-comparison-sites">fee per sale from insurers</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/heres-whats-actually-driving-up-health-insurance-premiums-hint-its-not-young-people-dropping-off-85683">Here's what's actually driving up health insurance premiums (hint: it's not young people dropping off)</a>
</strong>
</em>
</p>
<hr>
<p>Before taking out extras cover, see whether you are better off to self-insure: setting aside money for if and when you need to pay for extras such as dental or optical care. </p>
<p>Review your policy each year and talk to your health insurance fund about your changing needs. <a href="http://www.ombudsman.gov.au/about/private-health-insurance">Seek redress</a> if something goes wrong. </p>
<p>If you need a procedure, <a href="https://www.myhospitals.gov.au/">find out</a> the waiting period in the public system, rather than assuming it will be quicker in the private system. Check the out-of-pocket costs if you choose to use your private health insurance. Then you can assess whether the price tag is worth getting your surgery a few weeks earlier. </p>
<p><em>* This article originally said more than half of Australians had private health insurance. This has now been corrected to 45.8%.</em></p><img src="https://counter.theconversation.com/content/93661/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sophie Lewis receives funding from the Australian Research Council </span></em></p><p class="fine-print"><em><span>Karen Willis received funding from the Australian Research Council (2013-2015) to investigate choice and health care.
She has an Honorary appointment at Melbourne Health.</span></em></p>Private health insurance premiums will rise from April 1, leaving consumers wondering if they should give it up or downgrade to save money.Sophie Lewis, Senior Research Fellow, Centre for Social Research in Health, UNSW SydneyKaren Willis, Professor, Allied Health Research, Melbourne Health, LaTrobe University, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/894982018-02-08T18:12:33Z2018-02-08T18:12:33ZPublic hospital blame game – here’s how we got into this funding mess<figure><img src="https://images.theconversation.com/files/205422/original/file-20180208-74512-fyvrw4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The five yearly negotiations have long generated controversy and angst.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/0lrJo37r6Nk">Jair Lázaro</a></span></figcaption></figure><p>Discussions between state, territory and Commonwealth leaders at the <a href="https://www.coag.gov.au/">Council of Australian Governments</a> (COAG) meeting in Canberra today is likely to be heated, to say the least. Hospital funding is on the agenda, and we’ve already heard the states are unhappy with the deal Prime Minister Malcolm Turnbull is expected to present to them.</p>
<p><a href="http://www.smh.com.au/federal-politics/political-news/leaked-coag-papers-reveal-greg-hunt-s-new-hospital-funding-deal-20180206-p4yzhq.html">A leaked document shows</a> the government will propose a continuation of the current interim agreement. This would see the Commonwealth continue to pay 45% of the cost of hospital funding growth, with a 6.5% cap on spending growth, until 2025. The states <a href="https://www.theaustralian.com.au/national-affairs/state-politics/gladys-berejiklian-poised-for-win-in-consolidating-partnerships/news-story/1abcc038db3fa21790c03fcd40216c50">want more</a>. </p>
<h2>Blame game history</h2>
<p>Public hospitals in Australia are owned and operated by state (and territory) governments. So why does the Commonwealth government attract blame for lack of hospital funding? </p>
<p>Commonwealth funding to states for public hospitals started in 1945. By then, as the states had conceded the power to tax income to the Commonwealth, the Commonwealth had the greater revenue-raising power. Contributions from the Commonwealth to the states were negotiated through five-yearly agreements from that time. </p>
<p>The introduction of Medicare in 1984 entitled all Australians to free public treatment, thereby increasing hospital costs. States were compensated though higher Commonwealth contributions, still negotiated through five-yearly agreements. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-medicare-and-how-does-it-work-22523">Explainer: what is Medicare and how does it work?</a>
</strong>
</em>
</p>
<hr>
<p>Even back then, the five-yearly negotiations generated controversy and angst. At each round of negotiations <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1467-842X.1999.tb01538.x/abstract">debate ensued</a> about whether the Commonwealth and the states were paying their fair share of hospital funding. Negotiations in 1998 and 2003 were <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Health/Health/Final_Report">particularly acrimonious</a>. </p>
<p>The state of public hospitals was a major feature of the 2007 federal election, with then-prime ministerial candidate Kevin Rudd promising to “end the blame game”. Although health policy had been a feature in previous federal elections, it had not focused on public hospitals.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/hfe2Q6Sj4IU?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Rudd: “In the end, the Buck will stop with me”.</span></figcaption>
</figure>
<p>The <a href="http://www.federalfinancialrelations.gov.au/content/npa/health/_archive/national-agreement.pdf">2011 Health Reform Agreement</a> established a new approach, and took three years to resolve. It sought to provide long-term certainty around hospital funding, replacing the five-yearly negotiated agreements with a clear basis for the level of Commonwealth contribution. </p>
<p>The Commonwealth committed to an agreed share (45% for the first three years, then 50%) of the growth in public hospital costs. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/lost-about-health-care-reform-heres-where-we-got-to-in-2011-2997">Lost about health-care reform? Here's where we got to in 2011</a>
</strong>
</em>
</p>
<hr>
<p>Efficiency was to be assured through <a href="https://www.ihpa.gov.au/what-we-do/activity-based-funding">activity-based funding</a> (also known as case-mix funding) for hospitals. This sets a price per type of hospital episode, and hospitals are paid on the basis of the number of cases, adjusted by case type.</p>
<p>The “nationally efficient price” is currently based on the average cost of a procedure, test or treatment and is set by the <a href="https://www.ihpa.gov.au/">Independent Hospital Pricing Authority</a>. But volume growth was left to be addressed by the states as the “system managers”. </p>
<h2>Back to the drawing board</h2>
<p>Then came the Abbott government’s 2014 budget. The Commonwealth government delivered a nasty fiscal shock to the states by withdrawing from the 2011 agreement and limiting its hospital funding increases to population growth and general inflation. </p>
<p>As part of the 2011 deal with the states, the Commonwealth had guaranteed a minimum level of growth funding until 2019-20, even if this was higher than the “efficient growth” contribution. This meant that these cuts could only take effect from 2017-18. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/budget-takes-hospital-funding-arrangement-back-to-the-future-26701">Budget takes hospital funding arrangement back to the future</a>
</strong>
</em>
</p>
<hr>
<p>The unilateral action also did serious damage to the confidence and goodwill generated by the 2011 agreement. A partial respite from the foreshadowed cuts was achieved in April 2016 with <a href="https://www.coag.gov.au/about-coag/agreements/heads-agreement-between-commonwealth-and-states-and-territories-public">an agreement for the period 2017-18 to 2019-2020</a> for additional funding at 45% of the growth, but subject to a cap of 6.5% per year.</p>
<p>The 2016 agreement also commits the Commonwealth and states to develop a longer-term funding agreement before September 2018. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/another-day-another-hospital-funding-dispute-how-to-make-sense-of-todays-coag-talks-57058">Another day, another hospital funding dispute – how to make sense of today's COAG talks</a>
</strong>
</em>
</p>
<hr>
<h2>Future of hospital funding</h2>
<p>So what are the challenges to be addressed in this new agreement and how might they play out in the next seven months? </p>
<p><strong>Volume growth:</strong> Under the activity-based funding system, prices per unit of activity <a href="https://www.ihpa.gov.au/publications/ihpa-annual-report-2016-17">have stabilised</a>. But total expenditure equals unit price by volume, so while price is steady, increases in hospital admissions (and case severity) are driving growth in total expenditure. </p>
<p>It is clear both from theory and international experience that activity-based funding addresses the first (admissions) but not the second (volume). <a href="https://www.aihw.gov.au/reports/hospitals/ahs-2015-16-admitted-patient-care/contents/table-of-contents">Recent data shows</a> the number of admissions to public hospitals increasing by 3.5% a year over the past five years, with the rate increasing more in the most recent years. </p>
<p>Expect to see discussions about what appropriate volume growth is and how it will be managed.</p>
<p><strong>Private hospitals:</strong> Private hospital admissions have been <a href="https://www.aihw.gov.au/reports/hospitals/ahs-2015-16-admitted-patient-care/contents/table-of-contents">increasing at a faster rate</a> than public admissions. There has also been a <a href="https://www.ihpa.gov.au/publications">steady growth</a> in private patients treated in public hospitals. This exposes the Commonwealth to higher outlays through its subsidies for private insurance premiums. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/private-health-insurance-rebates-dont-serve-their-purpose-lets-talk-about-scrapping-them-91061">Private health insurance rebates don't serve their purpose. Let's talk about scrapping them</a>
</strong>
</em>
</p>
<hr>
<p>The recent <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/private-health-insurance-reforms-fact-sheet-private-patients-in-public-hospitals">private health insurance reforms</a> commit the Commonwealth to explore this issue with the aim of reducing the number of privately insured patients who use public hospitals.</p>
<p>Expect debate from the insurance funds, the private hospitals, and public sector advocates.</p>
<p><strong>Integrated funding models:</strong> The current approach for activity-based funding and the Independent Hospital Pricing Authority deals with, well, hospitals. </p>
<p>Improving health sector productivity <a href="https://www.ceda.com.au/Research-and-policy/All-CEDA-research/Research-catalogue/Improving-service-sector-productivity-the-economic-imperative">will require</a> a more system-oriented approach with the concept of a nationally efficient price extended to more health services, including those provided in the community. An “episode of care” extends beyond the hospital walls and includes GPs, specialists, pathology, pharmacy and so on.</p>
<p>This is a challenge which may be addressed or ignored.</p>
<p><strong>Responsibility:</strong> The 2011 agreement recognised the need for Commonwealth-state partnership around the health system. The <a href="http://www.budget.gov.au/2014-15/content/overview/html/overview_key_initiatives.htm">2014 budget</a> explicitly made funding public hospitals a state responsibility. The 2016 agreement is somewhat ambiguous, recognising the shared responsibility for health, without any explicit statement on public hospital funding responsibility.</p>
<p>The 2016 agreement bought some time for the states and Commonwealth to maintain a status quo. This new agreement will at best provide a long-term stable basis for the joint funding of health services. At worst, it marks a return to the pre-2011 agreement conditions of political rhetoric and blame.</p><img src="https://counter.theconversation.com/content/89498/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Hall receives funding from the National Health and Medical Research Council and the Australian Research Council. She is a Member of the Independent Hospital Pricing Authority.</span></em></p><p class="fine-print"><em><span>Rosalie Viney receives funding from NHMRC and ARC.</span></em></p>Public hospitals in Australia are owned and operated by state (and territory) governments. So why does the Commonwealth government attract blame for lack of hospital funding?Jane Hall, Professor of Health Economics and Director, Centre for Health Economics Research and Evaluation, University of Technology SydneyRosalie Viney, Professor of Health Economics, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/867482017-11-07T19:27:18Z2017-11-07T19:27:18ZInfections, complications and safety breaches: why patients need better data on how hospitals compare<figure><img src="https://images.theconversation.com/files/193336/original/file-20171106-1068-1wnnewk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Information on patients' experiences with their hospital care is often not reported back to public hospitals at unit or ward level.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-use-pen-writing-about-healthcare-741169387">Shutterstock/PongMoji</a></span></figcaption></figure><p>Australia’s health system is an information industry – it is awash with data. Tragically, though, the data is not well collated, not put into the hands of the people responsible for acting on it. Nor is it shared with patients.</p>
<p>Multiple “data sets” measure the safety of hospital care in Australia, but they are rarely linked, sometimes incomplete, and almost always delayed. We have lots of data about hospital safety, but it’s not used to make us safer when we have to go to hospital.</p>
<p>Information on patients’ experiences with their hospital care are often not reported back to public hospitals at unit or ward level, which makes working out where to start on improving care that much harder. Information about patients’ experiences in private hospitals is rarely reported publicly at all. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-can-we-save-lives-in-hospitals-start-by-looking-for-and-investigating-red-flags-52287">How can we save lives in hospitals? Start by looking for and investigating red flags</a>
</strong>
</em>
</p>
<hr>
<p>A Grattan Institute report released today, <a href="https://grattan.edu.au/home/health/">Strengthening safety statistics: How to make hospital safety data more useful</a>, analyses many of these data sources and identifies practical ways they can be improved.</p>
<h2>The routine data – a scarcely tapped resource</h2>
<p>One of the most underused resources to track the safety of hospital care is the “routine data”. This is the information collected on every patient discharged from every hospital in Australia. It’s a rich source of clinical information – it tells us each patient’s diagnosis and the procedures performed, as well as their demographics. </p>
<p>The routine data allows us to track what went wrong in hospitals, such as the rate of infections acquired in hospital, so better and worse hospitals can be identified and corrective action taken.</p>
<p>It is also comprehensive: the information is collected in both public and private hospitals. </p>
<p>Yet, inexcusably, private hospitals are left outside state safety monitoring of hospitals. The New South Wales Bureau of Health Information, for example, produces an <a href="http://www.bhi.nsw.gov.au/BHI_reports/Insights_Series/clinical-variation-in-mortality/_nocache#individual_hospitals">excellent report comparing hospital deaths rates</a>, but only for public hospitals. </p>
<p>A key recommendation of our report is that private hospitals be included in the standard safety monitoring approaches. Their performance should be analysed, and the results fed back to them and reported widely, in the same way as public hospitals reporting.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/some-private-hospitals-are-safer-than-others-but-we-dont-know-which-77096">Some private hospitals are safer than others, but we don't know which</a>
</strong>
</em>
</p>
<hr>
<h2>Clinical quality registries – separate sources</h2>
<p>Another major resource for measuring the safety of hospital care is “clinical quality registries”. These are standalone, separate collections of detailed data about particular treatments. The national <a href="https://aoanjrr.sahmri.com/">Joint Replacement Register</a>, for example, holds information about hip and knee replacements, including revision rates when something has gone wrong. </p>
<p>These registries are certainly valuable. But they would be much more useful if clinical problems they identified were notified to the people who can take action to fix the problem.</p>
<p>Yes, some registries do that already (although often there is too long a delay before the people who need to know get to know). But some registries act like “secret squirrels”: they know about safety problems but won’t share them with anyone but the person or clinical unit who contributed the data. Hospital managers – and patients – remain in the dark.</p>
<p>This is unacceptable for several reasons. Patients are denied information that might be useful to them, such as the complication rates for weight-loss surgery at a particular hospital. And clinicians alone often don’t have the resources, motivation or power needed to investigate and fix problems; they need the institutional support of hospital managers.</p>
<p>These types of registries were often started by dedicated and enthusiastic clinicians, with the best of intentions. These registries are well supported: many now receive public funding. And the number of such registries in Australia is growing.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/no-one-should-get-dud-hospital-care-its-time-to-lift-our-game-on-quality-and-safety-54561">No-one should get dud hospital care – it's time to lift our game on quality and safety</a>
</strong>
</em>
</p>
<hr>
<p>But there’s a problem. These registries operate independently; they are separated from other data sources. They are designed to imagine patients as isolated body parts or diseases. This means important data about an individual patient – for example, someone with a knee problem and heart disease – is housed in multiple, independent registries. Data are duplicated and the insights from one registry are not available to the other unless they are specifically linked. </p>
<p>So another of our key recommendations is that the information kept in these registries should be linked to the routine data, to enhance the value of both.</p>
<h2>Making the data more useful</h2>
<p>To make hospital data more useful, we must ensure all of it is as accurate, relevant and gets into the hands and minds of the people who need it – patients, doctors, and hospital managers. And to be truly accessible, the data needs to be presented clearly. </p>
<p>A surprising number of doctors struggle with statistical concepts. As a result, patients can be left confused and misled. More attention needs to be paid to displaying individual hospital results graphically, <a href="https://www.myhospitals.gov.au/getmedia/55d3614f-6b07-43c7-a898-ca32603d4d77/hp-if_sab_2013_14_rpt.aspx">comparing them to other hospitals in a way where differences can be easily seen</a>. Rates of hospital-acquired infections for public hospitals are published, but rates for other complications, such as pressure injuries, are not.</p>
<p>Better information by itself, no matter how high the quality, will not improve anything; it will only point to where action and improvement is needed. But the converse is also true: without good information, we don’t know where there might be problems.</p><img src="https://counter.theconversation.com/content/86748/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and Grattan uses the income to pursue its activities.</span></em></p><p class="fine-print"><em><span>Christine Jorm does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article. She is affiliated with Sydney University and the Grattan Institute and is a fellow of the Australian and New Zealand College of Anaesthetists. </span></em></p>We have lots of data about hospital safety, but it’s not used to make us safer or more comfortable when we’re admitted.Stephen Duckett, Director, Health Program, Grattan InstituteChristine Jorm, Associate professor, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/799102017-07-03T04:20:45Z2017-07-03T04:20:45ZAre private patients in public hospitals a problem?<figure><img src="https://images.theconversation.com/files/176179/original/file-20170629-16083-1jl1bey.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A new report has claimed public patients are worse off with increased numbers of private patients in public hospitals. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Recently, hospital and aged care provider association Catholic Health Australia (CHA) <a href="http://cha.org.au/images/CAT2006_Report_v4_FA_Low_Res_Digital.pdf">released a report</a> sounding an alarm bell at recent increases in the number of patients in public hospitals being urged to “go private”.</p>
<p>Public hospitals may encourage their patients to “go private” because it allows them to bill the patient’s health insurance and Medicare for costs incurred, rather than having to dip into their own limited budgets. Patients may be persuaded to use their private health insurance after being assured by the public hospital of no out-of-pocket costs, or being promised added extras such as a private room.</p>
<p>The report argued this trend may harm the private hospital sector by affecting profitability and investment decisions. It may also harm the interests of public patients if public hospitals discriminate in favour of treating private patients. </p>
<p>While aspects of these concerns may be valid, there may also be some benefits to public hospitals treating more private patients.</p>
<h2>A look at the figures</h2>
<p>The report is correct that the numbers of private patients in public hospitals are increasing, at an average of 10.5% per year since 2011-12. Public patients in public hospitals and private patients in private hospitals have also been increasing, but at slower rates of only 2.7% and 4.5% per year respectively since 2011-12. </p>
<p>But percentage rates of change can be misleading. In raw numbers, the increase in public patients in public hospitals (527,467) and private patients in private hospitals (576,135) has actually outstripped the raw increase in private patients in public hospitals (287,473). This is because public patient numbers are increasing from a much larger base (over five million) than private patients in public hospitals (less than one million).</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/176669/original/file-20170703-7743-aabvs5.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/176669/original/file-20170703-7743-aabvs5.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/176669/original/file-20170703-7743-aabvs5.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176669/original/file-20170703-7743-aabvs5.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176669/original/file-20170703-7743-aabvs5.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176669/original/file-20170703-7743-aabvs5.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=498&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176669/original/file-20170703-7743-aabvs5.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=498&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176669/original/file-20170703-7743-aabvs5.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=498&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<h2>Concerns with this trend</h2>
<p>The CHA report notes several concerns with the trend of increasing private patients in public hospitals. They note anecdotal evidence of public patients being pressured to “go private” with incentives including drinks vouchers, better food options and free parking. While these reports may seem concerning, it’s hard to base any change of policy on anecdotal reports.</p>
<p>More worrying is the suggestion that publicly-admitted patients in public hospitals are being discriminated against, for example by being made to wait longer for treatment. The CHA report cites data from an <a href="http://www.aihw.gov.au/publication-detail/?id=60129559537">Australian Institute of Health and Welfare report</a>, which shows waiting times on public hospital waiting lists for public patients (at 42 days) was more than twice that of private patients in public hospitals (20 days).</p>
<p>But this difference is hard to interpret. There may be many differences in diagnosis and disease severity between public and private patients, which may explain the waiting time gap. So we can’t conclude this is evidence of any form of “discrimination” against patients without private health insurance in the public hospital system from these figures.</p>
<p><a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1759-3441.2010.00058.x/abstract">More robust evidence</a> from public hospitals in NSW in 2004-05 does show private patients were prioritised over public patients. In this study, waiting times for elective surgery were found to be considerably shorter for private patients, despite having similar clinical needs as public patients. </p>
<p>Differences in waiting times between public and private patients were found to be largest for patients assigned to the lowest two urgency levels. In these cases, waiting times for public patients were more than twice as long as for private patients.</p>
<p>There is further evidence, also from NSW public hospitals, that public and private patients may be treated differently when they are assigned to an urgency category for waiting lists for elective surgery. <a href="http://www.healthpolicyjrnl.com/article/S0168-8510(14)00021-9/abstract">The study</a> suggested private patients were more likely to be assigned into more urgent admission categories, which corresponds with a shorter maximum wait for admission into hospital. </p>
<p>This study also found private patients were likely to receive more medical procedures while in hospital, but found no difference for length of hospital stay or, importantly, for mortality rates.</p>
<h2>Potential benefits</h2>
<p>One claim of the CHA report is that there has been relatively “stagnant” growth of activity of private patients in private hospitals, potentially affecting their profitability and investment decisions. </p>
<p>First, the figures don’t seem to back this up. The increase in numbers of private patients in private hospitals is actually higher than the increase in numbers of private patients in public hospitals. </p>
<p>Second, even if private hospitals were losing business to public hospitals, it could be a welcome demonstration of competition in the health care market. The trend may be explained through public hospitals providing better amenities, higher quality, or lower costs than private hospitals.</p>
<p>There are some arguments to support continuing the practice of public hospitals admitting private patients. There can be efficiency gains to the health system given that the fees and charges for private patients in public hospitals are usually lower than those in private hospitals. So this form of competition could lower the costs in the health system as a whole.</p>
<p>Additional revenue raised by public hospitals could also support the continual provision of services and programs for public patients, which may have been curtailed due to budget cuts to the public hospital system.</p>
<p>The public hospital system is often seen as unfairly treated by the private sector in how it bears costs for training junior doctors (which takes place overwhelmingly in the public system), and treating the most severely ill patients. From this perspective, it seems only fair to allow public hospitals to take their “share” of the more profitable private patients.</p>
<h2>Why we need better data</h2>
<p>It’s important to figure out whether private patients are receiving preferential treatment at the expense of public patients. <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1759-3441.2010.00058.x/abstract">One study</a> found abolishing preferential access for private patients and admitting patients according to when they were listed for an elective procedure would only lead to a small improvement in waiting times for public patients. </p>
<p>This is because long waiting times for public patients are primarily due to budget constraints in public hospitals, and not because private patients are skipping the queue.</p>
<p>The available robust evidence on the treatment of private patients in public hospitals is from more than a decade ago, and it’s unclear if the disparities between how public and private patients are treated have improved or worsened. </p>
<p>One reason for the lack of high quality research on this topic is the <a href="https://theconversation.com/why-dont-we-know-how-many-people-die-in-our-hospitals-71471">restriction on access to detailed hospital data in Australia</a>, which we need for robust studies. If we had access to more detailed data, we could better understand what’s happening now, and ensure timely access to high quality hospital care for both public and private patients.</p><img src="https://counter.theconversation.com/content/79910/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Sivey receives funding from the Australian Research Council.</span></em></p><p class="fine-print"><em><span>Terence Cheng 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>There may be some benefits to public hospitals treating more private patients.Peter Sivey, Associate Professor, School of Economics, Finance and Marketing, RMIT UniversityTerence Cheng, Senior Lecturer, School of Economics, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/770962017-06-12T19:57:14Z2017-06-12T19:57:14ZSome private hospitals are safer than others, but we don’t know which<figure><img src="https://images.theconversation.com/files/172387/original/file-20170606-15219-1qy5yi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Private health insurance allows you to choose which hospital to go to for treatment. But are some safer than others?</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/535212139?src=hpsgmvgX6YWpVm9icAmjmw-2-16&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>The <a href="http://www.telegraph.co.uk/news/2017/05/31/rogue-breast-cancer-surgeon-ian-paterson-sentenced-15-years/">recent jailing</a> of British breast surgeon Ian Paterson after performing multiple unnecessary operations has highlighted the issue of hospital safety.</p>
<p>Paterson’s unnecessary surgeries included some performed in private hospitals, which <a href="https://www.theguardian.com/society/2017/may/17/surgeons-call-for-review-of-safety-standards-in-private-hospitals-ian-paterson">prompted UK doctors</a> to call for private hospitals to report similar patient safety data as public hospitals, including unexpected deaths and serious injuries.</p>
<p>This example shows how little we know about patient safety and quality in our private hospitals, not only in the UK, but also in Australia.</p>
<h2>What do we know about hospital safety and quality?</h2>
<p>In Australia, one of the best places to look for information on hospital safety and quality is the <a href="http://www.myhospitals.gov.au/">MyHospitals</a> website, a commonwealth department site run by the <a href="http://www.aihw.gov.au">Australian Institute of Health and Welfare</a>. </p>
<p>The Australian Institute of Health and Welfare is provided with data about every patient treated in an Australian hospital, both public and private. Using that data, you can look up measures of safety and quality, as well as emergency department performances. You can compare public hospitals on all the performance measures, but private hospitals are excluded from the performance reports. </p>
<hr>
<p><em>Further reading: <a href="https://theconversation.com/what-are-better-public-or-private-hospitals-54338">Which are better, public or private hospitals?</a></em></p>
<hr>
<p>Another good source is the <a href="http://www.bhi.nsw.gov.au/">New South Wales Bureau of Health Information</a>, which allows you to compare information about the <a href="http://www.bhi.nsw.gov.au/__data/assets/pdf_file/0003/356529/report-insights-exploring-clinl-variaication-in-mortality2017.pdf">safety and quality</a> of public hospitals in NSW. Private hospitals are not included.</p>
<h2>Private hospitals are not all the same</h2>
<p>Private health insurance <a href="https://theconversation.com/explainer-why-do-australians-have-private-health-insurance-38788">allows you to choose</a> your treating doctor and the hospital at which you’re treated. But how do you choose the right hospital, or the safest one? As our research shows, not all private hospitals in Australia are equal.</p>
<p>In 2009, the Australian Health Insurance Association (now called Private Healthcare Australia) asked me and my colleagues to look at the outcomes of care in private hospitals. We looked at death rates and the numbers of people who died during their stay in hospital, and a range of other safety and quality outcomes.</p>
<p>We were given access to three years of detailed data from a national sample of patients treated in 58 private hospitals. We did not know the names of the hospitals, nor patients’ names.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/172389/original/file-20170606-16864-1xh6jv9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/172389/original/file-20170606-16864-1xh6jv9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/172389/original/file-20170606-16864-1xh6jv9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/172389/original/file-20170606-16864-1xh6jv9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/172389/original/file-20170606-16864-1xh6jv9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/172389/original/file-20170606-16864-1xh6jv9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/172389/original/file-20170606-16864-1xh6jv9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/172389/original/file-20170606-16864-1xh6jv9.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">Our research showed some private hospitals were safer than others, but from the data we analysed we couldn’t tell which.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/381538246?size=medium_jpg">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Many kinds of hospital outcomes, such as the likelihood of dying in hospital, or contracting a serious infection, are influenced by factors such as a patient’s age, and the range of conditions that brought them to hospital. We tried to take those factors into account and <a href="http://www.privatehealthcareaustralia.org.au/wp-content/uploads/Ben-Tovm_D.pdf">published our findings</a> on the Private Healthcare Australia website.</p>
<p>We found a group of hospitals that, each year, seemed to have much lower death rates than average for all the private hospitals. Those, or other hospitals, also had lower than average rates of a variety of non-fatal incidents. There was also a group of hospitals that each year had higher than average death and adverse event rates. The greater than average death rate group included hospitals where death rates were consistently up to 90% higher than average. </p>
<p>If you are choosing a hospital, you’d want to know which hospital was which. But that information is not publicly available. You’d also want to know if there were more recent statistics, but there is no reported follow-up study. Without better public access to such facts and figures, we’re still in the dark.</p>
<h2>What do other countries do?</h2>
<p>Other countries do things differently. In the US, several groups provide <a href="http://www.euro.who.int/__data/assets/pdf_file/0020/263540/Public-reporting-in-health-and-long-term-care-to-facilitate-provider-choice-Eng.pdf?ua=1">extensive and detailed information on a range of hospital safety and quality outcomes</a> for almost all US hospitals, including private hospitals. The groups, which do not always agree, include commercial (<a href="https://www.healthgrades.com/">Healthgrades</a>) and not-for-profit organisations (<a href="http://www.leapfroggroup.org/">The Leapfrog Group</a>), and public and government bodies (such as <a href="https://www.medicare.gov/hospitalcompare/search.html?">Medicare Hospital Compare</a>).</p>
<p>And in England, it is easy to look up the Care Quality Commission’s <a href="https://www.cqc.org.uk/what-we-do/services-we-regulate/hospitals">detailed reports</a> about public and private hospitals. The reports provide an easy to read, “blow-by-blow” account of their inspections of all types of hospitals, and make a variety of judgements on what they find. They are backed up by detailed statistical reports, but only for public hospitals.</p>
<p>Why don’t we do this in Australia?</p>
<p>A representative from the <a href="https://www.oaic.gov.au/">Office of the Australian Information Commissioner</a> tells me that, provided individuals are not identified, there would be no breach of privacy if private hospital safety and quality data was made public. And no-one from a state health department has yet been able to say whether such a publication would be against any law.</p>
<p>Private Healthcare Australia, the peak body for health insurers, <a href="http://www.privatehealthcareaustralia.org.au/about-us/our-role/">says</a> it represents:</p>
<blockquote>
<p>over 12.9 million Australians who choose better quality health care services and to put their health care needs first.</p>
</blockquote>
<p>Private hospitals and private health insurers are in competition with each other for the 12 million or more Australians covered by some form of health insurance. So, it is in their commercial interests to avoid bad publicity. </p>
<p>Surely it is the role of both state and commonwealth governments to balance these commercial interests against the public’s right to know which hospital is providing safe, high-quality care.</p><img src="https://counter.theconversation.com/content/77096/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Ben-Tovim has received funding from the Australian Institute of Health and Welfare, the Australian Commission on Safety and Quality in Healthcare, the National Hospital Performance Authority, and Private Healthcare Australia</span></em></p>Australians can’t tell which private hospital is safer then the next because the data isn’t publicly available. It’s time that changed.David Ben-Tovim, Professor, Clinical Epidemiology & Process Redesign, Flinders UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/689802016-11-21T19:24:20Z2016-11-21T19:24:20ZIs the investment in private health insurance worthwhile?<figure><img src="https://images.theconversation.com/files/146699/original/image-20161121-30375-1my2zcp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's basically impossible to tell the difference between various policies and levels of cover. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>A frequent topic of conversation at any social or workplace gathering is the cost and unfairness of private health insurance. Despite guaranteed free treatment in public hospitals, we are both conditioned and persuaded to purchase a costly product that too often fails to deliver value for money or provide the expected choices and peace of mind.</p>
<p>Now, for the first time in 15 years, as <a href="http://www.abc.net.au/news/2016-03-02/private-health-insurance-premiums-to-rise-6-per-cent/7212488">premiums</a> and <a href="http://www.ombudsman.gov.au/about/private-health-insurance/private-health-insurance-publications/private-health-insurance-quarterly-bulletin/archived-private-health-bulletins">complaints</a> rise, the proportion of the population with private health insurance is declining. And <a href="http://www.news.com.au/finance/money/budgeting/private-health-exodus-premium-rises-lead-to-membership-decline/news-story/8041d9ffe7d9c6d9f877afeecfd2cd4f">recent polling</a> shows 20% of those who have private health insurance (46.8% of the population) expect to downgrade or drop their cover in the next six years.</p>
<h2>Why health insurance customers are unhappy</h2>
<p>Most of the antipathy towards private health insurance seems to be related to service and price, with premiums increasing at rates well above inflation. But there are also concerns about lack of transparency about what is covered, waiting periods and exclusions, and unexpected out-of-pocket costs.</p>
<p>The <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/PHIconsultations2015-16">public consultations</a> held by Health Minister Sussan Ley in late 2015 found <a href="https://www.theguardian.com/australia-news/2016/nov/17/market-failure-private-health-insurance-only-worth-it-for-the-pregnant-the-rich-and-the-sick">common themes</a>: poor value for money; high out-of-pocket costs; and lack of transparency and complex regulations. </p>
<p>Media stories tend to highlight the <a href="http://www.abc.net.au/news/2016-02-04/private-health-funds-behave-'outrageously'-in/7140250">rejection of claims</a> without appropriate medical review and the <a href="https://www.choice.com.au/money/insurance/health/articles/junk-health-insurance">raft of exclusions</a>, which unsuspecting policy holders often discover too late.</p>
<p>Minister Ley has promised action on several fronts, but changes seem a long way off. The 2015 public consultations have yet to produce any direct response. A <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2016-ley007.htm">media release</a> in February 2016 promised cheaper premiums as a consequence of prostheses pricing reforms. However, the recommendations in the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/iwg-phi-pros-ref">final report from the Industry Working Group</a> have yet to be acted upon and so are unlikely to have any impact on premium increases in 2017. </p>
<p>In September 2016, the minister announced the establishment of the <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2016-ley056.htm">Private Health Ministerial Advisory Committee</a> to provide advice on private health insurance reforms. This committee will not report until late 2017.</p>
<p>While the Turnbull government debates how to respond to public concerns within the constraints of its ideological support for privatised health care, and health funds try to lure us with marketing offers, Australians who are querying the affordability and value of private insurance must make their own assessments and take their own, appropriate actions. This is not easy as trusted resources and advisers without conflicts of interest are few.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/146700/original/image-20161121-30384-1gpxucg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/146700/original/image-20161121-30384-1gpxucg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/146700/original/image-20161121-30384-1gpxucg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/146700/original/image-20161121-30384-1gpxucg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/146700/original/image-20161121-30384-1gpxucg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/146700/original/image-20161121-30384-1gpxucg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/146700/original/image-20161121-30384-1gpxucg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/146700/original/image-20161121-30384-1gpxucg.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">Government announcements on protheses won’t make health insurance cheaper for a while.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<h2>Is the investment worthwhile?</h2>
<p>It is virtually impossible to directly compare policies and costs. It’s estimated that about <a href="https://www.theguardian.com/australia-news/2016/nov/17/market-failure-private-health-insurance-only-worth-it-for-the-pregnant-the-rich-and-the-sick">40,000 variations of private health insurance policies</a> are available. What these cover depends on a range of agreements individual funds have with private hospitals and doctors, and patients are not privy to these agreements. </p>
<p>Certain checks are essential at the time of purchase, based on health status and age. It makes no sense for a young woman to have a policy that excludes childbirth, or for an older woman to have a policy that covers it.</p>
<p>For starters, people with private health insurance should look at their medical and financial histories and likely futures. Most people should be able to assess for, say, the past five years, what they have paid in private health insurance premiums, what benefits they have received and what additionally they have paid out-of-pocket in deductibles and gap costs. </p>
<p>If costs paid exceed benefits received, this raises questions about whether private health insurance is still viewed as a worthwhile investment.</p>
<p>A 2015 <a href="http://www.news.com.au/lifestyle/health/health-problems/is-this-proof-health-insurance-is-a-rip-off/news-story/fdcdcbf90930bc64eb8ad5297c277a82">analysis by CHOICE magazine</a> found the average annual premium for a basic hospital-only policy was A$1507. For a policy that included ancillaries (extras like dental and optical) it was A$2324. </p>
<p><a href="http://www.apra.gov.au/PHI/Publications/Pages/Quarterly-Statistics.aspx">Data from the Australian Prudential Regulation Authority</a> shows the average payment from insurer to patient per episode of care in September 2016 was A$2209 for hospital and A$60 for general treatment (medical/ancillary). </p>
<p>The average out-of-pocket cost to the patient was A$284.20 for hospital, A$48.01 for ancillary and A$129.02 for medical (in-hospital medical services). The gap payments for medical vary widely depending on location (A$257.31 in the ACT, A$46.10 in South Australia) and by speciality.</p>
<p>People who have experienced a hospitalisation (emergency or elective, as a private or public patient) will have a different, expanded set of experiences and financials to draw on. The subsequent health outcomes and their costs must be weighed against issues such as the importance of a private room, quality of care, whether choice was available and, if it was, the extent to which it was important.</p>
<p>Most careful analysts will quickly determine, as the <a href="http://www.news.com.au/lifestyle/health/experts-say-having-extras-private-health-insurance-doesnt-make-financial-sense/news-story/269e157dade739719679c44a7ec0b655">CEO of the Private Health Insurance Administration Council</a> has pronounced, that the purchase of ancillary cover is “irrational”. </p>
<p>The average benefit paid per service is quite low given the actual costs of those services – A$69 for optical, A$62 for dental, A$35 for physiotherapy, A$30 for chiropractic – and the total annual benefit paid per person for ancillary services is A$389. Such cover is not insurance but a tightly capped set of rationed benefits. Dumping ancillary cover could save the average family A$500 to A$1000 per year.</p>
<p>Dumping hospital cover is a more difficult decision. Financial factors such as the <a href="https://www.ato.gov.au/Individuals/Medicare-levy/Medicare-levy-surcharge/">Medicare Levy Surcharge</a> and the <a href="http://www.privatehealth.gov.au/healthinsurance/incentivessurcharges/lifetimehealthcover.htm">Lifetime Health Cover Surcharge</a> come into play. </p>
<p>However, most people with incomes above A$90,000 (A$180,000 for families) would pay considerably less in surcharges than the cost of an average policy, so self-insurance to enable the use of private health care as and when needed becomes a real option. But this simple accounting does not factor in the unknown (and unknowable) savings that may accrue from the bargaining power that funds have with private hospitals and doctors.</p>
<p>Other stakeholders in health care could help improve transparency in the system and assist decision making. Hospitals and doctors could be more upfront about costs and gap payments, especially the hidden costs of surgery from anaesthesiology and additional doctors who attend and bill. </p>
<p>Funds could make policies shorter and simpler, with exclusions and waiting periods clearly identified and fewer annual changes. The federal government needs to implement greater protections for those who purchase private health insurance and ensure better value for the substantial funds taxpayers invest in private health insurance, directly and indirectly, through the private health insurance rebate, premiums, Medicare reimbursements and out-of-pocket costs.</p>
<p>The essential question that remains to be answered is why taxpayers are heavily subsidising a product that is only purchased by half of them and used, even when sick, by even fewer? If private health insurance is to facilitate the choice for all Australians that the co-existence of public and private systems represents, then immediate and significant reforms are necessary.</p><img src="https://counter.theconversation.com/content/68980/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lesley Russell 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>For the first time in 15 years, as premiums and complaints rise, the proportion of the population with private health insurance is declining.Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/543382016-03-17T19:21:06Z2016-03-17T19:21:06ZWhich are better, public or private hospitals?<figure><img src="https://images.theconversation.com/files/114598/original/image-20160310-26283-17ckw3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The most common reason for choosing private hospitals is shorter waits for elective surgery.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-107400536/stock-photo-man-laying-in-a-hospital-bed-with-his-leg-raised-in-traction-with-flowers-and-cards-next-to-him.html?src=A_m07GiPC0QfE3cZrmJ02g-1-64">Richard Lyons/Shutterstock</a></span></figcaption></figure><p>Around <a href="http://www.apra.gov.au/Pages/phiac-redirect.aspx">half of Australians</a> have private health insurance. So if they need to go to hospital, they may have the option of going public or private. </p>
<p>Although some people try to research their options extensively, it’s a challenge to find any useful information about hospital options. Most rely on their own experiences, the experiences of friends and family, advice from their doctors, or what they see and hear in the media. </p>
<p>The <a href="http://www.apra.gov.au/Pages/phiac-redirect.aspx">biggest users</a> of private health insurance hospital benefits are 60- to 79-year-olds.
Women in their 20s and 30s also have a higher claim rate for maternity care. </p>
<p>But around <a href="https://theconversation.com/the-debate-were-yet-to-have-about-private-health-insurance-39249">a quarter of people</a> with private health insurance choose to use the public system.</p>
<p>Let’s look at how users choose whether to go public or private, and how the two systems compare.</p>
<h2>Users’ perceptions</h2>
<p>Participants in <a href="http://sydney.edu.au/health-sciences/research/healthcare-choice/index.shtml">our research</a> of health-care choices were happy to use the public hospital system for emergency or acute health issues. They valued the high-quality medical care provided in those situations. As one participant said,</p>
<blockquote>
<p>In terms of medical care, I don’t see that there’s a difference because our best doctors are in our public health system.</p>
</blockquote>
<p>They were also happy there were no costs to use public hospitals. </p>
<p>But because public hospitals deal with emergencies and acute care, they found it a stressful environment, where the nursing staff were overworked. They also felt they had little choice about their care. </p>
<p>In contrast, when people talked about the benefits of the private hospital system, they talked about the hospitals as calm, not rushed, with sufficient staff, lovely rooms and a much “nicer” environment to be in. </p>
<p>Participants also talked about the importance of choosing their own doctor. Their choice of private hospital was most likely to be made on the recommendation of their doctor, usually a specialist. </p>
<h2>How they compare</h2>
<p>Australia has more public hospitals than private hospitals. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/133608/original/image-20160810-9203-1fqryzw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/133608/original/image-20160810-9203-1fqryzw.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=614&fit=crop&dpr=1 600w, https://images.theconversation.com/files/133608/original/image-20160810-9203-1fqryzw.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=614&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/133608/original/image-20160810-9203-1fqryzw.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=614&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/133608/original/image-20160810-9203-1fqryzw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=772&fit=crop&dpr=1 754w, https://images.theconversation.com/files/133608/original/image-20160810-9203-1fqryzw.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=772&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/133608/original/image-20160810-9203-1fqryzw.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=772&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>But about two-thirds of elective surgery in Australia is provided in private hospitals. In 2009-2010, there were almost 1.9 million elective surgery procedures – 661,000 in public hospitals and 1.2 million in private hospitals. </p>
<p>In 2013-2014 in the <a href="http://www.aihw.gov.au/hospitals/">public system</a>, half of all patients were admitted for elective surgery within 36 days of being placed on the waiting list. Around 90% of all patients were admitted within 262 days. The list was longest in New South Wales, where patients waited an average of 49 days. </p>
<p>Waiting times are not available for the private sector, but they tend to be much shorter. </p>
<p>Your <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129551486">hospital stay</a> is likely to be slightly shorter in a private hospital (5.1 days, on average) than a public hospital (5.7 days). This difference may partly be explained by higher numbers of patients requiring more complex care in the public system.</p>
<p>The chances of <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129551482">something going wrong</a> – for example, contracting an infection, falling, or receiving the wrong medication – is slightly higher for public hospitals (6.7%) than private hospitals (4.1%). Some of this difference may be because private hospital treatment is more likely to be planned (elective surgery), for which the risk of infection is lower.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/115218/original/image-20160316-8465-1pc7ms0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/115218/original/image-20160316-8465-1pc7ms0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/115218/original/image-20160316-8465-1pc7ms0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/115218/original/image-20160316-8465-1pc7ms0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/115218/original/image-20160316-8465-1pc7ms0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=486&fit=crop&dpr=1 754w, https://images.theconversation.com/files/115218/original/image-20160316-8465-1pc7ms0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=486&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/115218/original/image-20160316-8465-1pc7ms0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=486&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Public hospitals are perceived as providing high-quality care, but in a stressful environment.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-132572702/stock-photo-empty-bed-in-busy-hospital-corridor-blurred-figures-with-medical-uniform-working.html?src=BnJkzIlWceFNuawRMX6MoA-1-13">VILevi/Shutterstock</a></span>
</figcaption>
</figure>
<p>While costs are difficult to compare, the <a href="http://www.pc.gov.au/inquiries/completed/hospitals/report/hospitals-report.pdf">Productivity Commission found</a> that general hospital costs (items such as ward nursing, hospital supplies and allied health services) are higher in public than private hospitals (A$2,552 versus A$1,953). </p>
<p>However, medical and diagnostics costs (which includes items such as x-rays and blood tests) are higher for private hospitals (A$798) than public hospitals (A$542). Prostheses costs were also higher: around A$542 in private hospitals compared with A$131 in public hospitals. </p>
<p>Treatment in the public system does not incur out-of-pocket expenses, whereas the choice to use a private hospital usually comes at a cost. On top of insurance premiums and excess payments to the insurance company, the <a href="http://www.apra.gov.au/PHI/PHIAC-Archive/Documents/Qtr-Stats-Report-Mar15.pdf">average out-of-pocket cost</a> per hospital episode is A$293.32, or 20% of the cost of private care. </p>
<p>Patients may also be charged gap fees for surgeons, anaesthetists, pathology and medical devices. </p>
<h2>Maternity care</h2>
<p>The choice to give birth in a private hospital is one reason people of childbearing age take out private health insurance. Around <a href="http://www.health.gov.au/internet/publications/publishing.nsf/Content/pacd-maternityservicesplan-toc%7Epacd-maternityservicesplan-chapter3">30% of all hospital births</a> occur in private hospitals.</p>
<p>Despite evidence of a greater likelihood of <a href="http://theconversation.com/birth-intervention-and-harm-more-likely-in-private-hospitals-26801">interventions such as caesareans</a> in private hospitals, women in our study did not perceive that there were any risks in birthing in the private system. Indeed, some did not view caesarean birth, or other interventions, as a risk. </p>
<p>While it’s unlikely anything will go wrong during a caesarean birth, all types of surgery carry a small risk of infections and other complications. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/115217/original/image-20160316-25523-1m3pu3a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/115217/original/image-20160316-25523-1m3pu3a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/115217/original/image-20160316-25523-1m3pu3a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/115217/original/image-20160316-25523-1m3pu3a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/115217/original/image-20160316-25523-1m3pu3a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/115217/original/image-20160316-25523-1m3pu3a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/115217/original/image-20160316-25523-1m3pu3a.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">Women want continuity of care.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-216720409/stock-photo-woman-right-before-giving-birth-in-hospital.html?src=pp-same_artist-264090722-Kx3aKW2t9gN6ZvxTQpSGSg-5&ws=1">mathom/Shutterstock</a></span>
</figcaption>
</figure>
<p>Although many public hospitals provide continuity of care from a midwife during pregnancy, there is a general perception that in the public system you will see a different provider every time; many women don’t want this for their pregnancy experience. They also value the amenities in private hospitals, such as having a private room. </p>
<h2>Consumers need better information</h2>
<p>When deciding whether to use the private system, being aware of the costs and having appropriate cover <a href="http://theconversation.com/explainer-why-do-australians-have-private-health-insurance-38788">is key</a>. People may be prepared to pay for private care if they think they will get a higher quality of care and not have to wait. But this may not always be the case.</p>
<p>People are often vulnerable and anxious when they need to use hospitals. This is one reason the Commonwealth and state governments need to improve the information available to consumers about the differences in clinical care, costs, waiting periods and facilities between the public and private systems.</p>
<hr>
<p><em><strong>This article is part of our series <a href="https://theconversation.com/au/topics/hospitals-in-australia">Hospitals in Australia</a>. Click on the links below to read the other instalments:</strong></em></p>
<ul>
<li><p><strong><a href="http://theconversation.com/the-problems-with-australias-hospitals-and-how-can-they-be-fixed-54248">The problems with Australia’s hospitals – and how can they be fixed</a></strong></p></li>
<li><p><strong><a href="http://theconversation.com/infographic-a-snapshot-of-australias-hospitals-56139">Infographic: a snapshot of Australia’s hospitals</a></strong></p></li>
<li><p><strong><a href="http://theconversation.com/from-triage-to-discharge-a-users-guide-to-navigating-hospitals-54658">From triage to discharge: a user’s guide to navigating hospitals</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/how-much-seeing-private-specialists-often-costs-more-than-you-bargained-for-53445">How much?! Seeing private specialists often costs more than you bargained for</a></strong></p></li>
<li><p><strong><a href="http://theconversation.com/why-do-we-wait-so-long-in-hospital-emergency-departments-and-for-elective-surgery-54384">Why do we wait so long in hospital emergency departments and for elective surgery?</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/heres-how-to-boost-hospital-funds-and-end-the-blame-game-54247">Here’s how to boost hospital funds and end the blame game</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/do-you-really-need-to-go-to-hospital-time-to-recentre-the-health-system-54406">Do you really need to go to hospital? Time to recentre the health system</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/no-one-should-get-dud-hospital-care-its-time-to-lift-our-game-on-quality-and-safety-54561">No-one should get dud hospital care – it’s time to lift our game on quality and safety</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/hospitals-dont-need-increased-funding-they-need-to-make-better-use-of-what-theyve-got-54815">Hospitals don’t need increased funding, they need to make better use of what they’ve got</a></strong></p></li>
</ul><img src="https://counter.theconversation.com/content/54338/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karen Willis received funding from The Australian Research Council (ARC) for a project called 'Navigating the Health Care Maze - the differential capacity to choose (2013-2015).</span></em></p><p class="fine-print"><em><span>Sophie Lewis does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Around a quarter of people with private health insurance still choose to use the public system. Why?Karen Willis, Associate Dean (Learning and Teaching), Faculty of Health Sciences, Australian Catholic UniversitySophie Lewis, Senior Research Fellow, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/534452016-03-15T19:08:19Z2016-03-15T19:08:19ZHow much?! Seeing private specialists often costs more than you bargained for<figure><img src="https://images.theconversation.com/files/114567/original/image-20160310-31852-g4aqx6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Patients often rely on their GP to make the choice of specialist for them through the referral process with little or no discussion of prices.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-226271230/stock-photo-surgeon-operating-live-shot.html?src=Jqcav0q_HU6g5J0V1JyTqQ-2-26">gtfour/Shutterstock</a></span></figcaption></figure><p>Around <a href="http://www.apra.gov.au/Pages/phiac-redirect.aspx">half of Australians have</a> private health insurance. Most of us know that if we need to see a private specialist, we may face some out-of-pocket fees between what the doctor charges and the rebate we receive from Medicare and, if we’re having a procedure or operation, our private health fund. </p>
<p>But why is it so difficult to find out exactly how much it’s going to cost to have that suspicious mole removed or to be admitted to hospital for that colonoscopy or hip replacement? </p>
<p>Outside of public hospitals, most clinical health services are essentially private markets. The Commonwealth government, through Medicare, provides a variety of subsidies to reduce the cost burden on patients but does not regulate prices. Doctors can charge what they like – or what the market will bear. </p>
<p>Patients can learn their local GP’s fees relatively quickly and make informed choices about whether to switch practices. Our <a href="https://www.melbourneinstitute.com/downloads/working_paper_series/wp2013n23.pdf">recent research</a> suggests GP practices facing strong local competition were more likely to keep their prices low.</p>
<p>But specialist prices are more obscure. Patients often rely on their GP to make the choice of specialist for them through the referral process, with little or no discussion of prices. And patients see specialists less frequently than GPs, so they don’t have the opportunity to learn about prices through repeated use. </p>
<p>There is a simple way of increasing price transparency so we all know how much services cost at alternative providers: make this a requirement for all specialists and publish the data on a government website such as the <a href="http://www.myhospitals.gov.au/">My Hospitals</a> portal. </p>
<h2>Specialist consultations</h2>
<p>Prices for specialists are high, with only <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/34A89144DB4185EDCA257BF0001AFE29/$File/MBS%20Statistics%20Financial%20Year%202014-15%20external%2020150714.pdf">around 30%</a> of consultations bulk-billed and an average out-of-pocket cost of A$65.73 (for those not bulk-billed).</p>
<p>The size of out-of-pocket costs may be influenced by the <a href="http://www.amawa.com.au/wp-content/uploads/2015/10/AMA-Fees-List-Nov-15.pdf">list of recommended fees</a> published annually by the Australian Medical Association. The AMA-listed fee for initial specialist consultations is A$166, almost twice the Medicare Benefits Schedule (MBS) fee of A$85.55. </p>
<p>For initial consultations with consultants, the listed fee is A$315, more than twice the MBS schedule fee of A$150.90.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/114572/original/image-20160310-31847-sktrj5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/114572/original/image-20160310-31847-sktrj5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/114572/original/image-20160310-31847-sktrj5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/114572/original/image-20160310-31847-sktrj5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/114572/original/image-20160310-31847-sktrj5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/114572/original/image-20160310-31847-sktrj5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/114572/original/image-20160310-31847-sktrj5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The AMA-listed specialist fees are roughly double the MBS fees.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/karolfranks/6957537942/">Karol Franks/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p><a href="http://onlinelibrary.wiley.com/doi/10.1002/hec.3317/epdf">Recently published research</a> by health economists at the University of Technology Sydney confirms that many specialists practise “price discrimination” – they charge higher prices to patients who can afford to pay more. This is often seen as an indicator of a lack of competition in an industry.</p>
<p>Specialists are less price-competitive because of the high barriers to entry into these professions. This leads to long waiting lists for consultations as well as high prices. </p>
<p><a href="https://www.hwa.gov.au/sites/uploads/HW2025_V3_FinalReport20121109.pdf">Health Workforce Australia</a> has identified psychiatry, obstetrics and gynaecology among important specialities with a current shortage that are likely to be under-supplied in the future. Causes include a lack of specialist training places, long training programs and falling working hours. </p>
<h2>Procedures and surgery</h2>
<p>Most patients who have private in-hospital elective procedures have health insurance that pays their hospital costs, subject to an excess on the insurance policy. But doctors’ fees are more complicated.</p>
<p>Doctors’ fees for such procedures are funded by Medicare with a “gap” payment, often reimbursed by private health insurance. Medicare will fund 75% of the “schedule fee”, with private health insurance usually funding the other 25%. </p>
<p>But Medicare <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/34A89144DB4185EDCA257BF0001AFE29/$File/MBS%20Statistics%20Financial%20Year%202014-15%20external%2020150714.pdf">data shows</a> only 13% of anaesthetics services and 47% of operations services (mainly the surgeons’ fees) are charged at the schedule fee. </p>
<p>This leads to an average patient contribution of A$76 for operations and A$126 for anaesthetics. This may be funded by private health in some cases, but not all. Often this will depend on the agreements reached between private health insurance companies, doctors and private hospitals. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/114568/original/image-20160310-31852-73un10.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/114568/original/image-20160310-31852-73un10.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/114568/original/image-20160310-31852-73un10.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/114568/original/image-20160310-31852-73un10.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/114568/original/image-20160310-31852-73un10.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/114568/original/image-20160310-31852-73un10.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/114568/original/image-20160310-31852-73un10.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">It’s difficult to know how much your total bill will be.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-265489313/stock-photo-hospital-aisle.html?src=v2IjMRyI9NCppXHuwdet2g-2-43">dailin/Shutterstock</a></span>
</figcaption>
</figure>
<p>Patients may be left in the dark about their final out-of-pocket costs until months after any private hospital procedure. These delays are caused by the fragmentation of the billing process: an operation or procedure often involves several doctors, such as a surgeon, anaesthetist, pathologists and radiologists. </p>
<h2>So what’s the solution?</h2>
<p>Health insurer Bupa has introduced <a href="http://www.independent.co.uk/news/business/news/bupa-offers-fixed-fee-surgery-as-uk-profits-take-turn-for-the-worse-8531854.html">fixed-price surgery</a> in the United Kingdom to reduce the “bill shock” associated with private elective procedures. Such a development would be welcome in Australia. </p>
<p>But the motivation is lower here due to the high take-up of private health insurance. We rely on insurance companies to do the bargaining with hospitals and doctors for us.</p>
<p>Price-transparency regulation has a lot of potential to reduce the hip-pocket impact on Australian patients. Specialists should be forced to publish a list of their fees online, which GPs can use, together with patients, when making referral decisions. This should put pressure on specialists to think twice about increasing their fees.</p>
<p>Liberal MP Angus Taylor, now assistant minister for cities and digital transformation, <a href="http://www.smh.com.au/federal-politics/political-opinion/angus-taylor-time-to-empower-patients-in-healthcare-20151029-gkmiwg.html">has called for</a> a “My Doctor” website to provide comparative quality information about doctors. This is a good idea and a natural extension of existing policies. If it does eventuate, publishing prices should be a key component of the comparative information. </p>
<p>Price transparency is no panacea but should be an important component of ensuring taxpayers and patients get good value for money out of the health system.</p>
<p>In the meantime, if you’re seeing a specialist or undergoing a procedure, ask questions about the cost of your care, especially referrals to specialists and private hospitals. You’re paying for a service from a private company and should be able to weigh the perceived benefits against the price before making an informed purchase.</p>
<hr>
<p><em><strong>This article is part of our series <a href="https://theconversation.com/au/topics/hospitals-in-australia">Hospitals in Australia</a>. Click on the links below to read the other instalments:</strong></em></p>
<ul>
<li><p><strong><a href="http://theconversation.com/the-problems-with-australias-hospitals-and-how-can-they-be-fixed-54248">The problems with Australia’s hospitals – and how can they be fixed</a></strong></p></li>
<li><p><strong><a href="http://theconversation.com/infographic-a-snapshot-of-australias-hospitals-56139">Infographic: a snapshot of Australia’s hospitals</a></strong></p></li>
<li><p><strong><a href="http://theconversation.com/from-triage-to-discharge-a-users-guide-to-navigating-hospitals-54658">From triage to discharge: a user’s guide to navigating hospitals</a></strong></p></li>
<li><p><strong><a href="http://theconversation.com/why-do-we-wait-so-long-in-hospital-emergency-departments-and-for-elective-surgery-54384">Why do we wait so long in hospital emergency departments and for elective surgery?</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/heres-how-to-boost-hospital-funds-and-end-the-blame-game-54247">Here’s how to boost hospital funds and end the blame game</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/what-are-better-public-or-private-hospitals-54338">What are better, public or private hospitals?</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/do-you-really-need-to-go-to-hospital-time-to-recentre-the-health-system-54406">Do you really need to go to hospital? Time to recentre the health system</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/no-one-should-get-dud-hospital-care-its-time-to-lift-our-game-on-quality-and-safety-54561">No-one should get dud hospital care – it’s time to lift our game on quality and safety</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/hospitals-dont-need-increased-funding-they-need-to-make-better-use-of-what-theyve-got-54815">Hospitals don’t need increased funding, they need to make better use of what they’ve got</a></strong></p></li>
</ul><img src="https://counter.theconversation.com/content/53445/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Sivey receives funding from the Australian Research Council and has previously been funded by Health Workforce Australia and the National Health and Medical Research Council.</span></em></p>Why is it so difficult to find out exactly how much it’s going to cost to have that suspicious mole removed or to be admitted to hospital for that colonoscopy or hip replacement?Peter Sivey, Senior Lecturer, Department of Economics and Finance, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/561392016-03-14T19:14:40Z2016-03-14T19:14:40ZInfographic: a snapshot of hospitals in Australia<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/115743/original/image-20160321-4417-gsin6g.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/115743/original/image-20160321-4417-gsin6g.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=7449&fit=crop&dpr=1 600w, https://images.theconversation.com/files/115743/original/image-20160321-4417-gsin6g.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=7449&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/115743/original/image-20160321-4417-gsin6g.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=7449&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/115743/original/image-20160321-4417-gsin6g.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=9362&fit=crop&dpr=1 754w, https://images.theconversation.com/files/115743/original/image-20160321-4417-gsin6g.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=9362&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/115743/original/image-20160321-4417-gsin6g.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=9362&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure><img src="https://counter.theconversation.com/content/56139/count.gif" alt="The Conversation" width="1" height="1" />
What are the most common reasons for going to hospital? What can go wrong? What’s behind the state-Commonwealth funding fight? Our at-a-glance infographic has the answers.Fron Jackson-Webb, Deputy Editor and Senior Health EditorWes Mountain, Social Media + Visual Storytelling EditorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/449652015-07-21T20:17:20Z2015-07-21T20:17:20ZRemind me again, what’s the problem with hospital funding?<figure><img src="https://images.theconversation.com/files/89149/original/image-20150721-24298-glg9w9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The issue came to a head last year when the federal budget ripped billions of dollars of hospital funding from the states.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/multiple_users.mhtml?f=1">Shutterstock</a></span></figcaption></figure><p>State and territory leaders will meet in Sydney today to nut out solutions to health and education funding gaps. New South Wales Premier Mike Baird will again call for <a href="http://www.theaustralian.com.au/national-affairs/state-politics/mike-bairds-fix-for-budgets-gst-of-15pc/story-e6frgczx-1227448391481">the GST to increase to 15%</a>, while Victorian Premier Daniel Andrews will recommend <a href="http://www.theaustralian.com.au/subscribe/news/1/index.html?sourceCode=TAWEB_WRE170_a&mode=premium&dest=http://www.theaustralian.com.au/national-affairs/health/medicare-levy-should-go-up-andrews-to-tell-coag/story-fn59nokw-1227448225615&memtype=anonymous">increasing the Medicare levy</a> to cover the shortfall. </p>
<p>Treasurer Joe Hockey is expected to propose the <a href="http://www.afr.com/news/politics/raise-the-gst-and-fund-yourselves-treasurer-joe-hockey-to-tell-states-20150714-gibked">states take full responsibility</a> for funding public hospitals if the GST does indeed rise. </p>
<p>But what exactly is the problem the leaders are trying to address? And how did we get into this mess? </p>
<p>First, let’s go back to last year’s budget, when the issue came to a head. As health economist Stephen Duckett <a href="https://theconversation.com/federal-health-spending-is-forecast-to-slow-but-states-face-rising-bills-38493">neatly summarised</a> on The Conversation,</p>
<blockquote>
<p>The 2014-15 budget took an axe to Commonwealth payments to the states for health care. It abruptly terminated grants to states under the ironically named National Partnership Agreements, and, from 2017, sliced more than $1 billion a year from public hospital grants through reduced indexation.</p>
</blockquote>
<p><strong>Commonwealth funding cuts to hospitals</strong></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/89137/original/image-20150721-24270-lzbiah.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/89137/original/image-20150721-24270-lzbiah.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/89137/original/image-20150721-24270-lzbiah.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=459&fit=crop&dpr=1 600w, https://images.theconversation.com/files/89137/original/image-20150721-24270-lzbiah.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=459&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/89137/original/image-20150721-24270-lzbiah.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=459&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/89137/original/image-20150721-24270-lzbiah.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=577&fit=crop&dpr=1 754w, https://images.theconversation.com/files/89137/original/image-20150721-24270-lzbiah.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=577&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/89137/original/image-20150721-24270-lzbiah.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=577&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Last year’s budget cut billions of dollars of hospital funding, due to take effect from 2017-18. It also removed funding guarantees for public hospitals.</span>
<span class="attribution"><a class="source" href="http://budget.gov.au/2014-15/content/overview/download/Budget_Overview.pdf">Budget 2014-15</a></span>
</figcaption>
</figure>
<p>So, the Abbott government modified the agreements the Rudd-Gillard government transacted with the states and territories to assist with funding growth. </p>
<p>The federal contribution to the states and territories remains a key source of funding, but indexed growth funding <a href="http://budget.gov.au/2014-15/content/overview/download/Budget_Overview.pdf">is to be cut</a> from 2017. This puts more pressure on the states and territories to meet the growing cost of health care. </p>
<h2>Health costs</h2>
<p>Australia <a href="http://www.aihw.gov.au/australias-health/2014/health-system/">spent</a> about A$140 billion on health care in 2011-2012. That’s about A$6,000 per person each year. Hospital care accounted for nearly 40% (A$53 billion) and medical care in the community cost nearly A$10 billion. Medications cost almost A$19 billion. </p>
<iframe src="https://datawrapper.dwcdn.net/fkjFc/1/" frameborder="0" allowtransparency="true" allowfullscreen="allowfullscreen" webkitallowfullscreen="webkitallowfullscreen" mozallowfullscreen="mozallowfullscreen" oallowfullscreen="oallowfullscreen" msallowfullscreen="msallowfullscreen" width="100%" height="300"></iframe>
<p>The reason hospital costs are of outstanding importance to the states is that, unlike general practice and medications, they pay for them. Of the A$53.5 billion hospital services (both public and private) received in 2011-12, the state and territory governments <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129548869">paid</a> 42.8%, while the Commonwealth contributed 36.5%. Non-government sources provided the remaining 20.7%.</p>
<p>And the cost of funding hospitals is rising, as you can see by this chart.</p>
<iframe src="https://datawrapper.dwcdn.net/R6mEE/1/" frameborder="0" allowtransparency="true" allowfullscreen="allowfullscreen" webkitallowfullscreen="webkitallowfullscreen" mozallowfullscreen="mozallowfullscreen" oallowfullscreen="oallowfullscreen" msallowfullscreen="msallowfullscreen" width="100%" height="400"></iframe>
<p>State contributions for <em>all</em> health care rose from 23.2% to 27.3% from 2001-2002 to 2011-2012, while Commonwealth contributions fell from 44.0% to 42.4%. It is a continuation of this trend of less Commonwealth/more state and territory contributions – and the risk that hospitals will swallow more of the state budgets – that irks the premiers. </p>
<p><strong>Ratio of health expenditure to tax revenue</strong> <br>
<strong>%</strong></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/89136/original/image-20150721-24298-ysed5j.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/89136/original/image-20150721-24298-ysed5j.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/89136/original/image-20150721-24298-ysed5j.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=333&fit=crop&dpr=1 600w, https://images.theconversation.com/files/89136/original/image-20150721-24298-ysed5j.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=333&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/89136/original/image-20150721-24298-ysed5j.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=333&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/89136/original/image-20150721-24298-ysed5j.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=419&fit=crop&dpr=1 754w, https://images.theconversation.com/files/89136/original/image-20150721-24298-ysed5j.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=419&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/89136/original/image-20150721-24298-ysed5j.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=419&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 proportion of tax revenue states and territories spend on health is increasing, while the proportion the Commonwealth spends is decreasing.</span>
<span class="attribution"><a class="source" href="http://www.aihw.gov.au/australias-health/2014/health-system/">AIHW.</a></span>
</figcaption>
</figure>
<p>Premiers are also concerned about the trajectory of growth: <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442457498">Australian Institute of Health and Welfare modelling from 2008</a> projected that annual hospital expenditure would more than double from 2012-13 to 2032-22, from A$36 to A$81 billion. </p>
<h2>Why are health costs rising?</h2>
<p>When considering rising health-care costs, it’s important to note that dollars spent may simply reflect growing prosperity. With more money to spend it is hardly surprising that we devote more to health care. Indeed, health care is a “superior” good, meaning there is no natural upper limit to our investment, as there may be for “normal” goods such as food. </p>
<p>As the Australian Institute of Health and Welfare <a href="http://www.aihw.gov.au/australias-health/2014/health-system/">explains</a>:</p>
<blockquote>
<p>health expenditure tends to correlate with increased revenue more strongly than [with] increased demand for health services.</p>
</blockquote>
<p>So the proportion of our expenditure on health may rise as our aspirations grow, partly driven by an awareness of what new technology can do to ease and prolong our lives. This has been the pattern for years within OECD countries.</p>
<p>But this doesn’t remove the difficulty the states and territories face in raising revenue to meet the demand of rising expectations from an expanding and ageing population and reduced contributions from the Commonwealth. </p>
<p>The problem is probably not as dire as it has been portrayed, but we may as a nation choose to cut our cloth differently. If we wish to increase the state and territory contribution to hospital costs, states and territories will need to generate the necessary revenue. This is where the debate moves into the territory of changes to the taxation system and the agenda of today’s leaders’ summit.</p><img src="https://counter.theconversation.com/content/44965/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Leeder 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>State and territory leaders will meet in Sydney today to nut out solutions to health and education funding gaps. But what exactly is the problem they’re hoping to address?Stephen Leeder, Emeritus Professor, Menzies Centre for Health Policy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/360622015-01-15T03:54:55Z2015-01-15T03:54:55ZEpisiotomy during childbirth: not just a ‘little snip’<figure><img src="https://images.theconversation.com/files/69076/original/image-20150115-3018-1bibofs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Episiotomies have a place in maternity care but should not be routinely performed. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/30171854@N05/12215673796">Paul Curto/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>It’s difficult to imagine how something as big as a baby’s head can come out of what appears to be a relatively small space. But during childbirth, the perineum – the area of skin and muscle between the vagina and anus – stretches to allow the baby’s head through. </p>
<p>If the baby is showing signs of distress and needs to be delivered quickly or the mother’s health is in jeopardy, the midwife or doctor may recommend cutting the perineum with surgical scissors to enlarge the opening of the vagina. This is called an episiotomy. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/68961/original/image-20150114-31690-vtahhe.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/68961/original/image-20150114-31690-vtahhe.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/68961/original/image-20150114-31690-vtahhe.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=494&fit=crop&dpr=1 600w, https://images.theconversation.com/files/68961/original/image-20150114-31690-vtahhe.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=494&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/68961/original/image-20150114-31690-vtahhe.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=494&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/68961/original/image-20150114-31690-vtahhe.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=621&fit=crop&dpr=1 754w, https://images.theconversation.com/files/68961/original/image-20150114-31690-vtahhe.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=621&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/68961/original/image-20150114-31690-vtahhe.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=621&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Medio lateral episiotomy.</span>
<span class="attribution"><a class="source" href="http://commons.wikimedia.org/wiki/File:Medio-lateral-episiotomy.gif">Jeremy Kemp</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Episiotomies gained popularity among clinicians in the mid-20th-century and became almost routine. They were described as the “unkindest cut” by some and “just a little snip” by others. </p>
<p>We’ve since learnt clinically unwarranted episiotomies <a href="http://jama.jamanetwork.com/article.aspx?articleid=2089343">can cause</a> unnecessary pain, laceration and more serious perineal trauma when the cut extends. Compared with a natural tear, an episiotomy is generally more painful, leads to greater blood loss and takes longer to heal. </p>
<p>But despite <a href="http://www.ncbi.nlm.nih.gov/pubmed/16128977">international health bodies</a> advocating a restrictive rather than routine approach to the procedure, episiotomy rates remain high among women who give birth in private hospitals in many countries – including Australia. </p>
<h2>A short history of the episiotomy</h2>
<p>Historical accounts claim <a href="http://www.glowm.com/section_view/heading/Episiotomy/item/128">Sir Fielding Ould</a> first advocated the procedure in 1742, describing the head as thrusting against the perineum as “if contained in a purse”. </p>
<p>Episiotomies become much more popular in the early 20th century with the advocacy of <a href="http://en.wikipedia.org/wiki/Joseph_DeLee">Joseph DeLee</a>, a prominent Chicago obstetrician who laid the groundwork for modern obstetrics in the United States. </p>
<p>DeLee proposed eliminating the second (pushing) stage of childbirth by routinely using episiotomies and forceps under general anaesthesia. He described birth as “a decidedly pathological process” which was akin to falling on a pitchfork.</p>
<p>Between 1940 and 1980 episiotomies became routine in the US and, to a lesser extent, in the United Kingdom and Australia. By 1979, episiotomies ware performed in 63% of vaginal births in the US. </p>
<p>Widespread use of episiotomy was promoted as better facilitating the birth, protecting the baby’s head from trauma and preventing lacerations of the perineum and undue stretching of the pelvic floor. </p>
<h2>Restricting routine use</h2>
<p>It was not until the 1980s that women’s voices were heard in research, when <a href="http://www.amazon.com/Episiotomy-Second-Stage-Sheila-Kitzinger/dp/0937604070">Sheila Kitzinger</a> undertook a study that exposed the trauma women suffered from the procedure. </p>
<p>In 1984, the <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1442865">research</a> of Jennifer Sleep and colleagues showed no benefit from the practice of routine episiotomy. This was followed by several other trials that showed no benefit and more harm, in terms of pelvic floor weakness, painful intercourse after birth and perineal pain. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/68983/original/image-20150114-31690-1m6hxbh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/68983/original/image-20150114-31690-1m6hxbh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=422&fit=crop&dpr=1 600w, https://images.theconversation.com/files/68983/original/image-20150114-31690-1m6hxbh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=422&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/68983/original/image-20150114-31690-1m6hxbh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=422&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/68983/original/image-20150114-31690-1m6hxbh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=530&fit=crop&dpr=1 754w, https://images.theconversation.com/files/68983/original/image-20150114-31690-1m6hxbh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=530&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/68983/original/image-20150114-31690-1m6hxbh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=530&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Episiotomies can cause pelvic floor weakness, painful intercourse after birth and perineal pain.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&searchterm=childbirth&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=204818413">Circlephoto/Shutterstock</a></span>
</figcaption>
</figure>
<p>In 2012, a <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000081.pub2/abstract;jsessionid=904B3D919724ED3221EF5168C733098F.f01t04">Cochrane Systematic Review</a> collated the results of all the randomised controlled trials involving more than 5000 women. It showed there were significant benefits to restricting episiotomies, such as reduced perineal trauma, less suturing and fewer healing problems. </p>
<p>Episiotomies have a place in maternity care – and have the potential to save lives occasionally – but they should not be performed routinely. </p>
<h2>How common are episiotomies?</h2>
<p>We don’t have an optimal episiotomy rate. Some studies show excellent outcomes aiming for <a href="http://www.ncbi.nlm.nih.gov/pubmed/24770179">no episiotomies</a> and others suggest rates of around 5-10% are <a href="http://www.ncbi.nlm.nih.gov/pubmed/16128977">ideal</a>. The clinical need for the procedure also varies with different populations.</p>
<p>But health-care provider and place of birth appear to determine whether episiotomies are performed, suggesting they’re overused. </p>
<p>In the <a href="http://jama.jamanetwork.com/article.aspx?articleid=2089343">US</a>, new data shows episiotomy use overall has declined between 2006 and 2012, to 14.4%. But it remains high in some hospitals, with privately insured women more likely to undergo the procedure. </p>
<p>A slightly different trend is shown in Australia with a decline in episiotomy rates during the 1990s but a steady rise from 12.8% in <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442458935">2000</a> to 14.9% in <a href="http://www.aihw.gov.au/publication-detail/?id=6442468191">2006</a> and to 16.2% in <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129550054">2012</a>. Victoria has the highest rate at one in five deliveries. </p>
<p>There are several reasons for the Australian trends, including the fact that women are having fewer babies (episiotomy is more common with a woman’s first birth), changes in ethnicity due to migration (rates of episiotomy are higher among Asian and Indian women) and changes in private insurance status (rates are higher under private obstetric care).</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/68985/original/image-20150114-31670-luj6y8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/68985/original/image-20150114-31670-luj6y8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=878&fit=crop&dpr=1 600w, https://images.theconversation.com/files/68985/original/image-20150114-31670-luj6y8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=878&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/68985/original/image-20150114-31670-luj6y8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=878&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/68985/original/image-20150114-31670-luj6y8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1103&fit=crop&dpr=1 754w, https://images.theconversation.com/files/68985/original/image-20150114-31670-luj6y8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1103&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/68985/original/image-20150114-31670-luj6y8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1103&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The NSW rate of episiotomy in the private sector is double that of the public sector.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/davidswiftphotography/2200020849/in/photolist-4mpFxX-6vkK9r-fHdsN-aCLZaa-4gfZoW-bVzAwQ-4AEqoj-4nfh6R-fHdiQ-4eJE3B-37sud6-2hFb1Z-4Ak49z-bvue7U-9u1J7F-crYhms-4gc3Zv-crYhmJ-aCLiRb-4eNDJY-37sLsp-fBU2VD-4nVBsj-C3wFc-fC8zFb-bVzA9s-cqxeyG-4nRxER-eeA34p-C3wF6-dQRDd3-4ANjEf-4AEpuu-mGA1Dw-fCYyk-4AJ2PK-5t3Gaw-37x9N7-mXAt9X-4AA6zF-fHzZzw-fHzQ6u-fHjK7B-fHCheU-fHiRnk-fHkFwF-fHzvfA-fHBBiQ-fHzdmL-fHAdF5">DAVID Swift/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>In <a href="http://www.health.nsw.gov.au/hsnsw/Publications/mothers-and-babies-2012.pdf">New South Wales</a>, which records hospital-specific episiotomy rates, we see a range from 2.3% at Moree hospital to 43.1% in Westmead Private. The average rate in NSW is 26.3% in private hospitals, 14% in public hospitals. </p>
<p>Developed countries with no private health system, such as the UK, have much <a href="http://www.ncbi.nlm.nih.gov/pubmed/16128977">less variation</a> in episiotomy rates.</p>
<p>My research from <a href="http://bmjopen.bmj.com/content/2/5/e001723.full">2012</a> and <a href="http://bmjopen.bmj.com/content/4/5/e004551.full">2014</a> shows that even when women were low risk of complications during child birth, the NSW rate of episiotomy in the public sector was half that of the private sector. </p>
<hr>
<h2>An episiotomy is <em>more</em> likely when:</h2>
<ul>
<li>Having your first baby</li>
<li>Having a forceps or vacuum birth</li>
<li>Having a long second stage</li>
<li>Having an epidural</li>
<li>Giving birth lying on your back, especially with legs in stirrups</li>
<li>The baby’s head is in an abnormal position</li>
<li>The baby is very big</li>
<li>You have a private obstetrician as your care provider</li>
</ul>
<h2>An episiotomy is <em>less</em> likely when:</h2>
<ul>
<li>Having your second or subsequent baby</li>
<li>Giving birth in a side lying or upright position</li>
<li>Perineal massage has been done in the late stages of pregnancy</li>
<li>Your pelvic floor is relaxed</li>
<li>You birth the baby’s head slowly or between contractions</li>
<li>You have a baby in a birth centre or at home</li>
<li>You are cared for by midwives you know and have good support</li>
</ul>
<hr>
<h2>Protecting the perineum</h2>
<p>We now have good evidence about how to <a href="http://health.ninemsn.com.au/pregnancy/labourandbirth/695210/perfecting-the-perineum-during-pregnancy-and-birth">prepare the perineum</a> for childbirth. </p>
<p>My research shows that using a <a href="http://www.ncbi.nlm.nih.gov/pubmed/18021143">perineal warm compresses</a> in the second (pushing) stage of childbirth increases women’s comfort and reduces the severest form of perineal trauma. This is now <a href="http://summaries.cochrane.org/CD006672/PREG_perineal-techniques-during-the-second-stage-of-labour-for-reducing-perineal-trauma">widely recommended</a> during birth. </p>
<p>We also know that undertaking <a href="http://summaries.cochrane.org/CD005123/PREG_antenatal-perineal-massage-for-reducing-perineal-trauma">perineal massage</a> – gently stretching the perineum with the fingers – in the last five to six weeks before birth can reduce the need for episiotomy, especially with first babies. </p>
<p>Giving birth in an <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002006.pub3/abstract">upright position</a> also reduces the need for an episiotomy and forceps delivery. </p>
<p>Finally, giving birth at <a href="http://www.bmj.com/content/343/bmj.d7400">home or in a birth centre</a> leads to <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4067683/">lower rates of episiotomy</a> and severe perineal tearing, as does having <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004667.pub3/abstract">the same midwife</a> throughout pregnancy and birth.</p>
<p>Women have never considered an episiotomy a little snip and while most evidence-based health providers today agree, some are taking longer to change entrenched practices. The internet abounds with stories of women feeling they had an <a href="http://www.huffingtonpost.com/2012/08/22/episiotomy-childbirth-guidelines_n_1799394.html">episiotomy against their will</a> and many describe the trauma they suffered. </p>
<p>As with any surgical procedure, if an episiotomy is warranted, informed consent should always be sought and gained before one is ever carried out.</p>
<p><em>* An earlier version of this article incorrectly said the episiotomy rate at Kareena Private was 39.2%. This has now been updated.</em></p><img src="https://counter.theconversation.com/content/36062/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hannah Dahlen receives funding from the ARC and NHMRC. She is affiliated with the Australian College of Midwives</span></em></p>It’s difficult to imagine how something as big as a baby’s head can come out of what appears to be a relatively small space. But during childbirth, the perineum – the area of skin and muscle between the…Hannah Dahlen, Professor of Midwifery, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/268012014-05-22T00:51:47Z2014-05-22T00:51:47ZBirth intervention – and harm – more likely in private hospitals<figure><img src="https://images.theconversation.com/files/49086/original/nxmyzqch-1400645802.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Babies born in private hospitals are more likely to have a problem following birth and to be readmitted to hospital in their first 28 days.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/martinlabar/2230004679">Martin LaBar/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>Australia has high rates of medical and surgical intervention (including caesarean section) during birth, especially in private hospitals. </p>
<p>While these interventions can be harmful if overused, people working in the private sector have argued they’ve resulted in better health for babies. <a href="http://bmjopen.bmj.com/content/4/5/e004551.full">Research we have just published</a> using a large population-based sample shows this is not so.</p>
<p>Birth interventions include labour being induced, the mother being given an epidural (anaesthetic in the spine for pain relief), birth by caesarean section, the <a href="https://theconversation.com/from-barber-surgeons-to-car-mechanics-the-technologies-of-vaginal-birth-20474">use of forceps or a suction cup</a> (vacuum birth) on the baby’s head for delivery, and a surgical cut to the perineum (episiotomy) to make the vaginal opening wider.</p>
<p>Such interventions should only be used where there’s a medical need (if either the mother or the baby is unwell, for instance, or the birth is taking too long). And since they create new risk, women should be told about the benefits and risks of the intervention before it takes place.</p>
<h2>High intervention rates</h2>
<p>In 2012, we <a href="http://bmjopen.bmj.com/content/2/5/e001723.full">published research</a> showing low-risk women having their baby in private hospitals in New South Wales had much higher rates of obstetric intervention than those giving birth at a public hospital. </p>
<p>Expecting mothers are categorised as low risk if they are under 35 years of age, have a full-term baby (37 to 42 weeks) with normal birth weight, don’t smoke and have no medical or obstetric complications. These latter include high blood pressure, diabetes, and previous caesarean section, twins or breech birth, among other things. </p>
<p>Looking at data from 2000 to 2008, we found only 15% of low-risk first time mothers in private hospitals had a normal vaginal birth without intervention compared to 35% in public hospitals. Overall, first-time mothers had a 20% lower chance of having a normal birth in private hospitals compared to public hospitals. </p>
<p>When we published our findings, privately-practising <a href="http://bmjopen.bmj.com/content/2/5/e001723.full/reply#bmjopen_el_6458">obstetricians defended their intervention rate</a>, recognising it was high but noting it was worth doing to save babies’ lives. This makes perfect sense but we wanted to know whether there was any evidence for this position.</p>
<h2>Seeking evidence</h2>
<p>The result was a paper we’ve just <a href="http://bmjopen.bmj.com/content/4/5/e004551.full">published in BMJ Open</a>. For this research, we looked again at low-risk women giving birth in New South Wales between 2000 and 2008. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/49088/original/rnhvssyt-1400646264.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/49088/original/rnhvssyt-1400646264.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/49088/original/rnhvssyt-1400646264.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/49088/original/rnhvssyt-1400646264.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/49088/original/rnhvssyt-1400646264.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/49088/original/rnhvssyt-1400646264.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/49088/original/rnhvssyt-1400646264.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">Trauma from birth interventions can affect how mothers connect with their newborn babies.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/lulieboo/4350213532">Lauren Nelson/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>But this time, we examined problems that required medical attention following birth and readmission to hospital within the first 28 days of life as well as the rate of intervention at birth. We also looked at stillbirths and infant deaths up to 28 days following birth. </p>
<p>We found babies born in private hospitals were more likely to be born before 40 weeks gestation (as they are more likely to have their labour induced or have an elective caesarean section before 40 weeks) and they were more likely to have some form of resuscitation at birth. </p>
<p>They were also more likely to have a problem following birth and to be readmitted to hospital in their first 28 days for <a href="http://www.patient.co.uk/doctor/birth-injuries-to-the-baby">birth trauma</a> (mostly scalp trauma) (5% vs 3.6%); hypoxia (lack of oxygen during birth) (1.7% vs 1.2%); <a href="http://raisingchildren.net.au/articles/jaundice_of_the_newborn.html/context/644">jaundice</a> (4.8% vs 3%); feeding difficulties (4% vs 2.4%); sleep or behavioural issues (0.2% vs 0.1%); breathing problems (1.2% vs 0.8%) and <a href="http://www.racp.edu.au/page/paed-policy">circumcision</a> (5.6% vs 0.3%). </p>
<p>All except the last of these may be associated with higher rates of medical intervention. They also lead to a longer stay in hospital following birth, and separation of mother and child.</p>
<p>Most significantly, there was no difference in the death rates between babies born in the two types of hospitals.</p>
<h2>Disempowering mothers</h2>
<p>But why had the obstetricians responding to our 2012 report thought their higher rates of intervention had been saving babies’ lives? Part of the reason may be <a href="https://www.mja.com.au/journal/2009/190/9/adverse-outcomes-labour-public-and-private-hospitals-australia-population-based">a 2009 paper</a> that concluded better health for babies born in private Australian hospitals. </p>
<p>Unfortunately, this research had only looked at one data set (we looked at five) and did not control for important risk factors, such as low birth weight which can lead to more deaths and medical problems in the baby.</p>
<p>And there is an even bigger problem with wider ramifications here. A <a href="http://www.biomedcentral.com/1471-2393/14/62">recent Queensland study</a> showed a significant number of pregnant women are not consulted in decision-making about the medical procedures they undergo, or informed of their risks and benefits. </p>
<p>This can lead to trauma and feelings of disempowerment about the birth. It may also impact how mothers connect with their newborn baby. Some women are so traumatised, they become depressed and even <a href="https://theconversation.com/for-some-women-unassisted-home-births-are-worth-the-risks-5179">develop post traumatic stress disorder</a>. In some cases, women choose to birth at home next time with or without a midwife in attendance (freebirth).</p>
<p>Women about to give birth should question interventions to assess whether they’re necessary. For those with low-risk healthy pregnancies, private obstetric care in a private hospital, with their higher rates of intervention may be leading to avoidable health problems for their babies. </p><img src="https://counter.theconversation.com/content/26801/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hannah Dahlen receives funding from the NHMRC and ARC. She is affiliated with the Australian College of Midwives.</span></em></p><p class="fine-print"><em><span>Sally Tracy 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>Australia has high rates of medical and surgical intervention (including caesarean section) during birth, especially in private hospitals. While these interventions can be harmful if overused, people working…Hannah Dahlen, Professor of Midwifery, Western Sydney UniversitySally Tracy, Professor in Midwifery, University of SydneyLicensed as Creative Commons – attribution, no derivatives.