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HealthWrap: Health care homes, hot policy topics – and the latest public health news

In the latest edition of The Health Wrap, Associate Professor Lesley Russell (who outed herself on national radio this morning as a “health policy tragic”) investigates primary health care reform, and the latest developments and debates around out of pocket costs and private health insurance.

She also shares some recommended reading, and beneath the column are “tweets of note”, sharing resources on non communicable disease control, health reform, and cultural safety (and much more too…).


Health Care Homes: an innovation doomed to failure?

The Turnbull Government has touted Health Care Homes as one of the biggest health system reforms since the introduction of Medicare.

But from the beginning there have been concerns about this initiative – it is underfunded, payment mechanisms are inappropriate, the time frames for evaluation are too short, essentially only one model is being trialled, there is a lack of consumer consultation, and many are nervous about the involvement of the private sector. The failure to address these issue and others meant that the roll-out of this initiative was delayed.

Now Dr Steve Hambleton, former head of the AMA and a GP who led the government’s expert advisory group on Health Care Homes, has admitted that the “implementation went wrong somewhere” and that the initial enthusiasm for what was promised has been lost.

Hambleton said both the RACGP and the AMA had backed down on their initial support (it is not clear whether he was saying this was due to changes in leadership) and highlighted the importance of this approach as a way of highlighting the value of general practice.

Unfortunately this important story, based on remarks by Dr Hambleton to the International Health Care Reform Conference in Sydney, was reported only in Australian Doctor, which is not accessible to the public.

There are many reasons to mourn the apparent early failure of the only recent significant reform in healthcare and to push for a revival of interest and a boost in commitment from all the stakeholders.

The Federal Government in particular must show leadership; it’s telling there has been no response from the Minister for Health, Greg Hunt, to this recent criticism, and his support for the initiative begun by his predecessor Sussan Ley has been muted at best.

An evaluation report released last year of the New Zealand Health Care Homes model, first implemented in 2010 but not yet rolled out nationally, highlights that positive and sustainable changes can be delivered for both patients and providers, but this requires substantial investments in time and effort.

Expecting dramatic changes in primary care practice, improvements in health outcomes and cost savings will take time, regardless of the models being trialled.

But to highlight that reform in primary care is not totally a lost cause in Australia, and that there are some great pockets of innovation, take a look at the work the NSW Agency for Clinical Innovation is doing to develop localised integrated health and social networks in “Healthcare Neighbourhoods”.


Private health insurance & out of pocket costs – issues that won’t go away

Healthcare is always an issue at election time: I think we can be certain that both private health insurance (PHI) and patients’ out of pocket (OOP) costs will be on the agenda the next time the nation goes to the polls.

However, there’s no optimism for thinking that either of the major parties has any realistic solutions or any enthusiasm for addressing these contentious issues.

So it will be up to consumers and patients to ensue these issues and their resolution are front and centre and to dismiss the inevitable scare campaigns that the politicians will try to run. They can do this by demanding evidence-based action over rhetoric and ideology.

New data highlights the enormity and impact of out-of-pocket costs

The Consumers Health Forum has just released their report Out of Pocket Pain. It highlights how OOP costs are strongly linked to use of PHI and private care.

The report found that 38 percent of those people with autoimmune conditions, 27 percent with breast cancer, and 18 percent with chronic illness have paid out more than $10,000 in OOP costs in the past two years. One in three of these people reported that no one had discussed the possibility of large costs and their right to shop around.

The report finds that greater transparency around fees and costs and insurance policies are needed (in terms people can understand) and also that patients need to know more about the choices that are available to them for their treatment. For example, waiting times for most procedures in most public hospitals are quite acceptable and coordinated cancer care, including psychosocial support, is much more likely in the public system.

Perhaps the most shocking aspect of this report’s release was the responses of the Australian Medical Association (doctors), Private Healthcare Australia (PHI funds) and the Australian Private Hospitals Association (private hospitals).

None of these groups acknowledged that their members have a responsibility to address their part in these costs. It’s clear that consumers must look to government regulation for protection and redress.

PHI debate continues as premium increases take effect

The budgets of 11 million Australians with PHI took a hit on April 1 when Government-approved premium increases took effect. Check out the recent Croakey article explaining these premium increases since 2000 here.

Then you might take a few minutes to check out what this means for you. Several years ago, I did the calculations for our family and realised that, even with regular dental visits, new glasses and contacts annually and an occasional physiotherapy visit, we were spending far more on ancillary cover than we ever recouped.

So it’s gone – and my sums show we are well ahead financially.

This year, faced with a $10 increase per month, I looked at getting better value for hospital cover and was able to keep the same level of cover and excess for $48 per month less. A classic example of why health policy wonks should practise what we preach – evidence-based decision making and understanding the choices involved!

My continuing cynicism (you noticed?) about whether we can expect any political action on this front is reinforced by the way the Turnbull Government (and the PHI industry) played the scare card about Labor’s statement that, in government, they would “look at” the PHI rebate.

Pretty quickly Labor walked back this statement, saying it would only remove the rebate from “junk” policies.

In doing so they likely have painted themselves into a corner – what if a Productivity Commission review of PHI (which Labor has promised it wins the next federal election) recommends additional changes to the rebate?

The dental divide

As we discuss affordability, accessibility, OOP costs and inequalities – will dental care and oral health be part of the debate? Even as the dental divide grows, it seems to have fallen off the agenda for everyone except those needing dental care and unable to afford it.

Two recent reports should focus attention on dental health. Results from the latest Royal Children’s Hospital National Child Health Poll, released last month, revealed rates of tooth decay are on the rise in Australia, particularly among young children. And polling released by Essential Report in February reveals that 48 percent of Australians favour abolishing the taxpayer subsidy for PHI and using the savings to establish a Medicare Dental Scheme (32 percent oppose such a change and 20 percent do not have a view).

In response, I wrote a piece that basically repeated what I had said in 2014, calling for an end to the artificial medical/dental divide and outlining six first steps towards the better integration of dental and medical care to improve health outcomes and contain overall health care spending.

Others went further. John Menadue has called for the $12 billion subsidy for PHI to be abolished and those funds allocated to universal dental care within Medicare. John Dwyer sees the failure to integrate dental and medical care as an Achilles heel of Australian healthcare and highlighted the “imperative that is the assumption of dental care into Medicare”.

This week Tim Woodruff, President of the Doctors Reform Society, in an article entitled Who cares about my toothless patients, makes the case that inequities in the status of oral health in Australia are the result of a failure of political will and the willingness to recognise that dental care should be a standard part of any healthcare system.

The one positive in this area is the development and release by the Australian Dental Association and the Australian Health Policy Collaboration of Australia’s first national report card on oral health – Australia’s Oral Health Tracker. This technical paper highlights the intrinsic link between oral health and preventable chronic diseases and their risk factors, identifies current indicators and has developed oral health targets for achievement by 2025.

It’s a worthy initiative that leaves a major question unanswered: where is government support for this work?


Effect of co-payments on utilisation of GP services

An interesting paper from Norway published last month looked at the impact of co-payments on the utilisation of GP services. The paper, unfortunately behind a paywall, is available here.

It found that co-payments (NoK 152 = US$15.5 in 2015, although there is no co-payment once a certain limit of expenditure is reached) reduce the utilisation of GP services but the effect is variable on patient groups. Patients with an acute condition exhibit low price sensitivity.

But the utilisation of GP services by patients with general complaints and symptoms, chronic diseases and psychological diseases was affected by the co-payment.

The paper indicates that the current flat fee co-payment policy is inefficient at targeting unnecessary use of the GP service at the cost of patients with real medical concerns.

This is a contentious issue that is accompanied by much mythology and ideology and surprisingly little evidence. Co-payments primarily act to shift at least part of the cost burden from healthcare funders to users. In doing so, they have been shown, in different healthcare and country contexts, to reduce utilisation.

However, there is no clear evidence that they have any impact on moral hazard (inappropriate or unnecessary use of services) or deliver substantial cost savings.

Rather, the more vulnerable and more disadvantaged are disproportionately affected, causing necessary healthcare to be deferred, increasing hospitalisation and complications, and giving rise to higher costs in the long term. There’s a good international summary of the issues (now a little dated) here and a more recent paper specifically on the effect of co-payments on primary care utilisation here.

The issue raised its ugly head here in Australia most recently when the Abbott Government, egged on by a proposal from the Australian Centre for Health Research, tried to apply a $7 co-payment to GP visits as part of the 2014-15 Budget. That did not go well for them: health policy analysts, doctors, consumers – and voters – were loud in their opposition, and the proposal was eventually withdrawn.

As mentioned, there has been surprisingly little research in this area and most of that work has been done in the US (where arguably it’s easier, in the absence of universal healthcare, to set up studies with and without co-payments). The archetypal study is the Health Insurance Experiment (HIE) conducted by RAND. Although it was completed several decades ago, in 1982, the HIE remains the only long-term, experimental study of cost sharing and its effect on service use, quality of care, and health.


Other reports on my reading list

• Australian Institute of Family Studies. Introducing competition and informed user choice into human services: Reforms to human services inquiry report. March 2018. Available at: https://aifs.gov.au/cfca/2018/03/28/report-introducing-competition-and-informed-user-choice-human-services-reforms-human

This report makes recommendations on how to apply increased competition, contestability and informed user choice to six previously identified human services: end-of-life care services; social housing; family and community services; services to remote Indigenous communities; health services; public dental services.

Australian Institute of Health and Welfare. Impact of alcohol and illicit drug use on the burden of disease and injury in Australia. Released March 2018. Available at: https://www.aihw.gov.au/reports/burden-of-disease/impact-alcohol-illicit-drug-use-on-burden-disease/contents/table-of-contents

This report highlights the size of the impact of alcohol on the burden of disease and on road fatalities. Unfortunately the data are from 2011, so the recent growth in misuse of opioids is not reflected in the analysis.

Parliament of Australia, Standing Committee on Health, Aged Care and Sport. Report on the Inquiry into the Use and Marketing of Electronic Cigarettes and Personal Vaporisers in Australia. March 2018. Available at: https://www.aph.gov.au/Parliamentary_Business/Committees/House/Health_Aged_Care_and_Sport/ElectronicCigarettes/Report 

Australia Institute. Charity still ends at home. The continuing decline of Australia’s official development assistance. April 2018. Available at: http://www.tai.org.au/content/charity-still-ends-home

This report comes amid rumours that Australia’s aid spending, already at record lows, could be cut further to 0.18 percent of Australia’s Gross National Income. This despite serious problems in our region, including reports about the havoc caused by climate change (see for example this recent Croakey piece on Kiribati), rising teen pregnancy rates in east Asia-Pacific and severe damage from a major earthquake in the Papua-New Guinea highlands.


Exercise is medicine

The 2 April edition of the Medical Journal of Australia is focused on exercise and sports medicine. This is very topical as we become couch potatoes, glued to the Commonwealth Games on TV.

Physical inactivity is the fourth leading cause of morbidity and mortality worldwide. But as a key paper in the MJA points out, there’s a large as evidence–practice gap between doctor’s knowledge of the contribution of physical inactivity to chronic disease and their routine assessment of patients’ physical activity and prescription of exercise as prevention and treatment for both physical and mental health. One of the key barriers is a lack of undergraduate training at medical schools. Doctors who exercise themselves are more likely to prescribe an exercise regime for their patients.

In particular, there is much to gain at both an individual and societal level from older people being physically active. Studies show the rates of sedentary behaviour increase with age. Less than half of Australians aged 65 years and over regularly do sufficient physical activity to produce a health benefit and about a third of the “insufficiently active” are completely sedentary.

It’s never too late to start being physically active and to reap the rewards, even if you can’t aspire to be like Julia Hawkins and take up running at 100.

…………………………………………………………………………………………………………………………………

If you follow me on Twitter (@LRussellWolpe) then you know that I am addicted to walking, and escape whenever possible to hike and explore landscape, culture, food and wine (I have this naïve idea that kilometres walked can offset calories consumed).

I’m off again on April 16 to Cornwall (Rick Stein food country) to walk from Tintagel to Port Isaac (home of the mythical Doc Martin) to Padstow and on to Mount St Michael, Penzance and Marazion. Stay tuned for my tweets – but no Health Wrap from me until May.

And stay tuned too for news of some more walking journalism events from #CroakeyGO.

  • Previous editions of The Health Wrap can be read here.
  • Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow on Twitter: @LRussellWolpe

ICYMI: Tweets of note, with links to resources

Read the report: Transforming health care in nursing homes: An evaluation of a dedicated primary care service in outer east London • Check out: The Pokies Play You
• Read the report: Beat NCDs

• Read: The Plain Packaging special edition of the QUT Law Review

Read: ‘Gendered Indigenous Health & Well-being within the Australian Health System: A Review of the Literature’

Read: Collection of essays at The Nation

• Check the Twitter stream reporting from this conference, #NCCC2018


• Read: ‘Which way? Talking culture, talking race’: Unpacking an Indigenous cultural competency course

And a final note from Professor Bronwyn Fredericks:

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