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The Health Wrap: Budget impact on women, health reform to watch, food as medicine, global Indigenous health and more

Melissa Sweet
Friday, May 25, 2018

The Health Wrap, Social determinants of health, Food and beverages, Indigenous health, Disabilities, Women's health, Abortion, Federal Budget 2018-19

In the latest edition of The Health Wrap, Associate Professor Lesley Russell looks at emerging detail from the #HealthBudget18, particularly its impact on women (most negatively on women with disability and Aboriginal and Torres Strait Islander women) and suggests seeing how it compares with the generosity of New Zealand’s “exemplar” budget.

In a bumper edition, she also keeps track of important health reforms from as far afield as New South Wales and the US state of Vermont, as well as benefits being delivered through Food as Medicine initiatives. She also celebrates the launch of the Indigenous Working Group at the World Federation of Public Health Associations (WFPHA) and the leadership role in that from Australian and New Zealand public health.

Beneath her column are links to some recommended new reading and “tweets of note”, sharing resources on social determinants of health and news about Manus/Nauru and the #hometovote hashtag as Ireland votes on changing its abortion laws.

Lesley Russell writes:

2018-2019 Federal Budget: what does it mean for women?

As always, it’s been a struggle to keep up with the Budget and its implications. It takes me days to wade through all the provisions, and it’s important to read beyond the spending and savings provisions in Budget paper No 2. I always examine the spending projections in Budget Paper No 1 and the federal/state partnership agreements in Budget Paper No 3. The Portfolio Budget Statements provide increasingly less detail every year, but there’s always something interesting lurking there, even if it’s only the program administration costs.

Croakey and contributors did a magnificent job in presenting the issues. You can read the collection of Budget articles here. Special kudos to Jennifer Doggett for her wrap of #HealthBudget18 done so speedily and artfully titled “The good, the bad and the absent”.

I contributed a piece to a summary on the health, aged care and research aspects of the Budget that The Conversation had out within an hour of the Treasurer finishing his speech. If you are looking for Budget information – in any area – the summaries prepared by the Parliamentary Library are a good place to start.

This year, for the second in a row, I did not do a complete Budget analysis, but was part of an amazing, all-women team that analysed the impact of the Budget on women (Gender Lens on the Budget 2018-2019). This report is done annually by the National Foundation for Australian Women, under the leadership of Marie Coleman: this year there are 176 pages of insights (not all of them good news). I wrote the sections on mental health and Indigenous affairs. Our overall conclusion was that disabled and Indigenous women really missed out. The analysis comes with recommendations for action – so let’s hope the politicians and the bureaucrats take notice of them.

There are a number of other analyses that apply a woman’s lens to the Budget, including:

Prime Minister and Cabinet Office for Women – Women’s Budget 2018-19 Snapshot
Australian Labor Party – Women’s Budget Statement 2018
Professionals Australia – What does the 2018 Budget mean for women?
Budget assessments by the ANU Centre for Social Research and Methods, University of Canberra’s NATSEM, and the Grattan Institute model the Budget impacts for different household types and income levels.

We are currently in the middle of Senate Estimates season. Let’s see what emerges; there are plenty of unanswered questions around the Budget provisions, including:

What is happening with possible reforms in primary care?
Where are the initiatives to ensure more seamless delivery of care and reduce out-of-pocket costs, especially for those with multiple chronic conditions?
Where are the efforts to tackle obesity?
Will the voices of Indigenous experts and communities be privileged and listened to as the Government proceeds with the Refresh Closing the Gap initiative?

BTW: If you want to see what a more generous national budget might look like, New Zealand’s is a great exemplar. The winners are public health, education and overseas development; there is more money to improve outcomes in social services and justice sectors and to address homelessness. You can read a summary here.

Whither healthcare reforms?

It’s a plaintive cry from health policy wonks, heightened currently because of the lost opportunities in the 2018-19 Budget.

Health Care Homes – what’s happening?

I have written previously about stakeholder concerns with the Health Care Homes (HCH) proposal.

The commencement date was 1 October 2017 (shifted from 1 July 2017), and the proposal was to have 200 practices providing HCH services from 1 December 2017. To May 2018, 170 practices in 10 Primary Health Networks (PHNs) have signed up to participate. The plan was for them to oversee the care of 65,000 patients but I have heard that enrolment numbers to date are much smaller than hoped. Maybe we will get more information from Senate Estimates on this? In the meantime, see this timely wrap from the Parliamentary Library.

Will New South Wales initiatives show the way?

In 2014 the New South Wales Government announced the investment of $120 million over 4 years to the Integrated Care in NSW Strategy.

These initiatives are now coming to an end. It will be interesting to see what we will learn – and whether the government/s of the day will continue to fund this important work.

Western Sydney is a focal point of innovation, driven by a strong partnership between Western Sydney Local Health District (WSLHD) and the Western Sydney Primary Health Network (WentWest). Their shared commitment to healthcare system reform meant there was enthusiasm about being named as one of three pilots.

In the forward to the mid-term report on Western Sydney’s Integrated Care Demonstrator program, issued in May 2016, Professor Stephen Leeder said, “While none of us can claim to have solid evidence about how best to provide care to people with serious and continuing illness, we know enough to establish experimental care arrangements… A brave beginning has occurred due to goodwill of practitioners and patients in all points of healthcare.”

When Leeder was interviewed about healthcare reforms during the recent #CroakeyGO Callan Park walk, he sighed when asked about the lack of needed federal efforts. But he thought healthcare professionals and the community were sufficiently concerned about current problems in the healthcare system/s that they would take on the reform agenda that the Commonwealth Government was ignoring. He expressed optimism that local initiatives and innovations, focused on better integration of care, could serve as exemplars for what can be achieved, and drive reforms from the bottom up – arguably a better, more sustainable solution than reforms imposed from the top down.

Leeder indicated that the report being finalised (I think he’s writing it!) from the Western Sydney Integrated Care Demonstrator program would show good progress towards desired outcomes. We will eagerly await these findings. Let’s hope that these (and those from the other two pilot sites) are made widely available and that there is continued funding and resources for this work.

Lessons from Vermont?

There are lessons to be learned from an experiment in a more integrated, community-driven approach to healthcare reform in the US state of Vermont. In 2014, after a failed attempt by the state governor to create a single payer healthcare system (it’s a fascinating story, you can read about it here), policy makers looked for other ways to achieve their key goals – lower costs and better outcomes. The proposal was to encourage the state’s largest payers of healthcare (Medicare, Medicaid and Blue Cross Blue Shield) to move from fee-for-service to risk-based contracting as operated by Accountable Care Organisations.

(As an aside: this why Obamacare will not go away – the innovations it proposes, like ACOs, are delivering needed reforms in terms of better integrated care and reduced costs. There are now more than 800 ACOs among public and private payers with a number of flexible models. They are not a silver bullet, and there are failures and failings, but there’s lots of ongoing evaluation. See for example this 2016 evaluation of the pioneer ACOs).

Vermont is a small state, and the OneCare ACO there operates state-wide. It has engaged half of the state’s doctors and nearly all the state’s hospitals, and it was prepared to do something different. Currently roughly one in every five Vermont residents, or 122,000 individuals, receive care under OneCare ACO.

The aim is to integrate physical and mental health and social services sectors in serving patients with the most complex needs. Under the state’s Blueprint for Health, Vermont already has a number of community-led strategies for improving health and wellbeing. Now hospitals are also linked in, using care coordinators already in the field. Their key role is to provide outreach to people seen as being at risk of hospitalisation.

To identify people who may need support, OneCare analysts use demographic information, data from the medical records of doctors and hospitals, and claims data supplied by payers. People are assigned into one of four categories based on their morbidity risk, and this categorisation is then provided to local care coordinators, who can adjust it based on their knowledge of the patients and conversations with clinicians. So socio-economic issues like a recent bout of homelessness or a death in the family are factored in.

People in Level 4 (complex/ high cost with acute catastrophic conditions) get a lot of attention (comprehensive health assessments, a shared care plan with assigned lead coordinator, outreach at least every month, care conferences) – but the savings accrue in hospital costs. There is also regular outreach to people seen to be a “rising risk”.

In addition to payments from Medicare, Medicaid and BCBS, the ACO has a state-funded budget of $621 million – $600 million for patient care, $12.5 million for operating expenses and about $7.5 million for pilot projects aimed at supporting the state’s health system. The ten hospitals participating in OneCare receive fixed monthly payments for providing care. Primary care providers get $3.25 per patient per month (supplementary to those from Medicare, Medicaid, BCBS) and providers caring for the sickest patients receive an additional $15 to $25 per patient each month.

A recent report from the Commonwealth Fund provides more information on this initiative. Think what we might learn in Australia from such an approach!

Food as medicine

There was an interesting story recently in the New York Times that highlights the growing recognition that delivering good health outcomes needs so much more than hospitals, doctors, nurses and prescription pads. California is experimenting with paying for nutritious meals to be distributed to chronically ill, low-income people who are on Medi-Cal (the Californian version of Medicaid). The hope is that this will lower medical costs and improve health outcomes.

The Medi-Cal pilot program will deliver specially formulated meals, as well as in-home visits from a registered dietitian, to 1,000 people with congestive heart failure — a patient group that has high rates of hospital admissions. The extremely limiting, salt-free diet that congestive heart failure patients must follow is challenging for people of any income level, but especially for those who sometimes have to choose between paying for healthcare and paying for food.

There is some evidence that this will work. A small study done in Philadelphia found that people on Medicaid who received free meals had average monthly medical costs 55 percent lower than Medicaid patients who didn’t get delivered meals. Hospital admission and duration rates were also significantly lower than the control group. Most strikingly, people who received meals and were later hospitalised were 23 percent more likely to be discharged back to their homes as opposed to a long-term care or rehabilitation facility when compared to the control group.

Another study found that patients receiving meals were less depressed, less likely to make trade-offs between food and healthcare, and more likely to maintain their medication regimes.

There’s a Food is Medicine Coalition in California that has helped spearhead this approach and others. Food as Medicine is no longer a fringe idea.

The strongest body of evidence for the value of providing meals to chronically ill patients comes from knowledge acquired during the AIDS epidemic. Food and Nutrition Services is now an integral part of the American Ryan White HIV/AIDS Program.

It is estimated that four percent of Australians experience food insecurity and cannot access sufficient, safe and nutritious food. The situation is described as reaching a “crisis point”. The rate of food insecurity is higher for certain population groups and marginalised communities such as asylum seekers (71%), Aboriginal and Torres Strait Islander peoples (22%), disadvantaged urban households (25%) and people who are unemployed (23%). Food insecurity can be both a precursor to, and a by-product of, chronic disease and poverty.

A landmark week for global Indigenous health

It’s been so exciting to follow the tweets from Associate Professor Carmen Parter (@CarmenParter – who was tweeting this past week as @IndigenousX ) and Summer May Finlay (@OnTopicAus – but also tweeting this past week for @WePublicHealth) from the Indigenous Working Group at the World Federation of Public Health Associations (WFPHA). Truly a landmark event for global Indigenous health, with great leadership from Australia and New Zealand. This is the first time there has been a specific focus on Indigenous health in the 51 years of WFPHA’s existence.

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: Reading and resources recommended by Croakey team

• The Royal Australasian College of Physicians has curated a long list of resources on the social determinants of health that many Croakey readers may find useful.