Introduction by Croakey: In the United States, North Carolina is using federal Medicaid funding to address the social determinants of health through initiatives such as the delivery of healthy food boxes, paying for someone’s first month’s rent or a security deposit, and case management for families experiencing domestic violence.
Meanwhile, Colorado is developing a similar plan, to use federal Medicaid funding to address the social needs of three groups of people: those who are homeless or at risk of homelessness, people with disabilities who are transitioning out of facilities, and young people aging out of foster care.
These initiatives are detailed in the latest edition of The Health Wrap, which also address pressing health reform needs in Australia, and the importance of access to “the beauties of nature”.
The quotable?
The track chairs give users of all ages, disabilities and styles the opportunity to hike on mountain trails, fish at two ponds and experience the roar of a mountain stream.“
Lesley Russell writes:
We are back in our Colorado home in the Rocky Mountains. Here we escape the heat dome that is plaguing much of the United States; daily temperatures are usually around 24°C, with sunshine, clear blue skies, no humidity and an occasional late afternoon thunderstorm.
We are doing lots of hiking and I’m eagerly chasing down wildflowers, identification guide in hand.
Needless to say, we cannot escape the endless political news here: it’s very worrying.
We should all be concerned for the future of American democracy and the impact its erosion will have internationally.
Climate change, extreme heat and brain health
As I am writing this edition of The Health Wrap, there are media reports that extreme heat in the United States has killed at least 28 people in the past week, and the toll is rising.
Heatwaves kill more people than any other extreme weather event and hot nights are considered more dangerous than daytime temperatures.
The consequences of extreme heat are not borne equally across populations. Work from the Kaiser Family Foundation shows that in the United States, people of colour and other underserved communities are disproportionately affected.
The higher mortality risks of these populations reflect increased exposure to heat due to underlying inequities such as poor housing, air pollution, and lack of green areas.
In Australia the past decade has seen increasing hospitalisations related to extreme weather, and heat is the biggest culprit.
The Australian Institute of Health and Welfare found that in the years 2019–20 to 2021–22, people aged 65 and over were most likely to be hospitalised for heat-related injuries. Across age groups, males had higher numbers of heat-related injury hospitalisations than females.
Australian data show that over 10 million Australians live in areas of very high to hazardous heat risk.
Australia doesn’t break this data down by race, ethnicity, or socioeconomic status, but a report produced earlier this year by the Australian Council of Social Services (ACOSS) showed that 80 percent of the people surveyed reported high temperatures in their homes had made them unwell; 14 percent of people were sufficiently unwell to see a doctor.
Most of these people had trouble paying their energy bills.
The ACOSS report also found 72 percent of Indigenous people had problems cooling their homes, an issue long advocated for in the top end of the country.
In a paper published late last year in Nature Climate Change, an international team of academics calls for research to explore the impact on the human brain of being exposed to more extreme weather events, such as heatwaves.
They believe such events may change brain structure, function, and overall health.
There is growing evidence of the impact of heatwaves due to climate change on the nervous system, brain development and mental health.
A recent review finds that climate change is worsening the symptoms of certain brain conditions, including stroke, migraines, meningitis, epilepsy, multiple sclerosis, schizophrenia, Alzheimer’s disease and Parkinson’s Disease.
The review reports evidence from studies conducted in the United States and South Korea that the incidence of ischaemic stroke increases with a rise in temperature and humidity.
In Madrid, hospital admissions related to Alzheimer’s disease increased by 23 percent for every daily temperature maximum that was more than 1°C higher than the heatwave threshold temperature of 34°C.
People with neurological and psychiatric diseases are at particular risk (see this recent editorial in The Lancet Neurology).
For example, as outlined in an article in the May 2023 issue of Brain, people with Dravet Syndrome cannot regulate their own body temperature, and they need to keep cool and well hydrated to avoid seizures which are provoked by high ambient temperatures.
Some drugs used to treat neurological and psychiatric conditions further complicate the problem by compromising the body’s ability to react to heatwaves by reducing sweating or disturbing the temperature-regulating machinery in the brain.
These issues are well summarised in a recent article in The Conversation.
Fee-for-service and value-based care
An article in Health Affairs looks at the issues that arise when value-based payments are promoted while fee-for-service payment (based on the US Medicare Physician Fee Schedule) continues as an intrinsic part of these alternative payment models but without needed reforms.
The article also discusses how the fee schedule can accommodate bundled payments and population-based payments that are also part of alternative payment models.
This is a discussion about American issues, but there is relevance for Australia.
In the United States, value-based payments in Medicare are primarily incentives for better management of conditions like end stage renal disease and for the prevention of hospital re-admissions.
The Centers for Medicare and Medicaid Services is also piloting several different bundled payment mechanisms.
The Health Affairs article points out that value-based payment and the fee schedule should be viewed as complementary, rather than as separate silos, and embedded flaws in the fee schedule must be fixed if value-based payment is to succeed.
These include payment distortions that compromise value by overpaying for certain procedures and imaging services while underpaying for services that add value for beneficiaries (such as long consultations).
To date little progress has been made in Australia in introducing alternatives to fee-for-service although the possibilities have been explored in several recent papers.
An Issues Brief from the Deeble Institute for Health Policy Research sees value-based payments as a necessary step towards securing Australia’s healthcare system sustainability by improving health outcomes and reducing waste.
A 2022 paper from the researchers at CHERE at the University of Technology Sydney describes options for value-based payment reform and highlights two challenges critical for success: attributing financial risk fairly and organisational structures.
When will Australia see action on moving towards more innovative payment models that will take into account the team-based care needed for the effective treatment and management of chronic conditions?
Here’s what Health Minister Mark Butler said in January 2023: “Medicare is an utterly central pillar of our healthcare system, but what is pretty clear to me is that the MBS rebate model, and Medicare funding more broadly, isn’t working for the disease profile the country now has: an older population with much more chronic disease.
“The idea of moving from a purely fee-for-service model that has largely defined Medicare over the last 40 years to something that’s more blended, that has more wraparound funding, particularly for older patients and patients with complex chronic diseases, is not a new idea.”
But nothing has been done since Labor was previously in office. Remember Health Care Homes? If you’ve forgotten, there is a good summary from the Parliamentary Library here.
The evaluation reports are here. The final report was not released until 2022.
The conclusion of this final report: “The Health Care Homes (HCH) trial achieved improvements in patient access and chronic disease management processes, but no significant change in patient experience, healthcare use outside of primary care or health outcomes.
“Conclusions about outcomes need to be interpreted in the light of the limitations described above, in particular that implementation of the HCH model amongst the participating practices was patchy, limited by scale, and not to the extent originally envisaged by the PHCAG [Primary Health Care Advisory Group]. Additionally, there was limited capacity to detect changes in outcomes given the short length of the trial.”
My conclusion: The patchy implementation, lack of timely guidance, failure to adhere to the agreed model and limited time to deliver outcomes should have been issues addressed prior to the conclusion of the trial.
The apparent failures (perhaps driven by a lack of commitment from the Coalition Government, which was responsible for the latter phases) are no excuse for not learning from these mistakes, barriers and issues – and proceeding with further trials like the HCH model.
Diabetes reports – now for some action
The State of the Nation 2024 report from Diabetes Australia shows the burgeoning number of Australians living with diabetes, up 32 percent from 2013–23, making it Australia’s fastest-growing chronic disease.
Type 2 diabetes (Diabetes Mellitus) is particularly increasing in younger people and the prevalence of youth-onset Type 2 diabetes in people aged 15–24 has doubled in Aboriginal and Torres Strait Islander communities in the past five years.
Type 2 diabetes should be regarded as a preventable disease but, as pointed out by Diabetes Australia, there is no national diabetes prevention plan.
The much anticipated diabetes report from the House of Representatives Standing Committee on Health, Aged Care and Sport, The State of Diabetes Mellitus in Australia in 2024, was released on 3 July.
The report makes 23 recommendations for government action (as reported by my Croakey colleagues Dr Melissa Sweet and with reactions compiled by Charles Maskell-Knight).
Regrettably (predictably?), most of these recommendations refer to issues of longstanding that should have been initiated years ago: food labelling reforms, a levy on sugar-sweetened beverages, addressing obesogenic environments, regulation of advertising of unhealthy food to children. They’ve long been ignored and almost certainly will be again.
As Professor Gary Sacks writes in The Conversation, we can’t afford to ignore the evidence any longer:
…we know Australian governments have historically been unwilling to introduce policies the powerful food industry opposes.
The question is whether the current Government will put the health of Australians above the profits of companies selling unhealthy food.”
Failures over the years to tackle these issues mean that so much more is required to address diabetes treatment, management and side effects.
The parliamentary report does address the need for improved access to glucose monitoring devices and insulin pumps and – importantly – the new Glucagon-like Peptide-1 (GLP-1) receptor agonists.
At a time when these new GLP-1 drugs are being promoted (often inappropriately) for weight loss and there are international shortages, it is imperative that the Pharmaceutical Benefits Scheme guidelines ensure that those at highest risk are able to access these medications on a regular and affordable basis.
Elsewhere in this edition of The Health Wrap I note the efforts that are required of patients with multiple chronic conditions – this would include many patients with Type 2 diabetes.
The report takes a very medical approach to the management of diabetes: it talks about the need for longer appointments, telehealth and access to allied health services.
This is what doctors’ groups are supporting. For example, the Royal Australian College of General Practitioners (RACGP) is calling for higher Medicare rebates for longer consultations and MBS rebates for patients to regularly see a GP for preventive care.
But in many cases what these patients need is care coordination and help with the activities of everyday living. Lots of individual medical appointments (with lots of associated out-of-pocket costs) constitute very real barriers for many people.
Diabetes Australia Group Chief Executive Justine Cain has called for “investment in integrated models of care that support multidisciplinary diabetes care teams, which deliver comprehensive diabetes management for individuals”.
As discussed elsewhere in The Health Wrap, it’s time to look to alternative models of care and Medicare funding mechanisms for the management of chronic illnesses.
Despite all the good intentions of the inquiry Chair Dr Mike Freelander and the members of the Standing Committee, and all the hard work of those who made submissions, the fact is that the latest parliamentary report adds little to the goals outlined in the Australian National Diabetes Strategy 2021-2030.
US initiatives on public health
Policy approaches
As in Australia, the COVID-19 pandemic has forced health policy and public health experts in the United States to consider how public health services might be better organised, funded and prepared for the inevitable future public health crises.
Public health responsibilities are shared between state and federal governments, so there is often significant relevance for Australia in these recent recommendations, especially as work is proceeding on the establishment of the Australian Centre for Disease Control.
- Health Affairs. June 2024. Reimagining Public Health: Mapping A Path Forward.
- Health Affairs. June 2024. The Community As A Full Partner: A New Model For Public Health.
Forging lasting connections between public health and age-friendly community efforts
Trust for America’s Health developed the Age-Friendly Public Health Systems (AFPHS) 6Cs Framework to provide broad guidance on how the public health field can advance services and policies that support the health and wellness of older adults.
- Issues brief: How the 10 Essential Public Health Services Align with the AFPHS 6Cs Framework for Supporting Healthy Aging. There is a podcast on this issue here.
Growing number of states are broadening Medicaid into a hub for fulfilling social needs
With the encouragement of the Biden Administration, Medicaid is threading health-related social needs such as food and housing into the program.
Because Medicaid (a healthcare program for the poor) is a joint responsibility of the federal government and states, each such expansion of the program requires federal approval. To date eight states have been approved and more are awaiting approval.
This is part of the Biden commitment to reduce health inequalities. You can read more about this effort here.
- A paper from the Kaiser Family Foundation outlined how Medicaid can address the social determinants of health.
In case you missed it
Impact of living with multiple long-term conditions (multimorbidity) on everyday life
An evidence synthesis, published on Research Square even as it was being peer reviewed, looks at the impact of living with two or more long-term conditions from the patient’s perspective.
Common difficulties experience by people living with multiple conditions included additional conditions over time, interactions between diseases, symptoms and treatments, the need to make constant decisions and prioritisations, and unpredictability and uncertainty.
These patients often feel they must serve as their own expert and advocate for their needs, and they find this exhausting.
The impact of living with multiple long-term conditions was experienced as a multifaceted and complex workload, much of which may be not apparent to healthcare professionals.
Current healthcare systems and policies are poorly equipped to meet the needs of this growing population.
Biomedical research funding restructure
The National Health and Medical Research Council (NHMRC) and the Medical Research Future Fund (MRFF) will work more closely under a new structure announced on 5 July.
The announcement says the new advisory structure and committees will “better harmonise and promote collaboration by key government funders in Australia’s health and medical research sector and make it easier for researchers to engage with funders”.
This announcement was in response to a consultation and a resultant report.
However, many details about this new arrangement are yet to be developed and/or made public.
See this thread from AAMRI and also more reaction in the latest ICYMI column.
Long COVID and pregnancy
A study just out in Obstetrics and Gynecology finds that nearly one in ten American women infected with SARS-CoV-2 during pregnancy developed long COVID.
This suggests long COVID is more prevalent among people infected while pregnant than in the American population overall.
Good news in Indigenous health
It was great to see Aboriginal and Torres Strait Islander people who have worked tirelessly for the health of communities and Country recognised in the 2024 NAIDOC awards.
The 2024 Lifetime Achievement Award was presented to Aunty Dulcie Flower AM, a foundation member and Elder of the Congress of Aboriginal and Torres Strait Island Nurses and Midwives (CATSINaM).
Read her full NAIDOC profile and details of the other award winners here.
The best of Croakey
Professor Megan Davis calls on Australians to renew their efforts to embrace the Uluru Statement from the Heart.
The good news story
If you have been following me on Twitter/X, then you will have seen the photos I have been posting of our hiking adventures in Colorado.
This is a wonderful outdoors state, with great sensibilities about the environment, climate change, sustainability, and the health and wellbeing blessings of being able to enjoy the beauties of nature.
Great Outdoors Colorado (GoCO) ties all that together with their work and the projects they support. The funding comes from Colorado Lottery proceeds, as determined by Colorado voters.
I only recently learned about the Track Chairs program, a joint initiative of GoCO and Colorado Parks and Wildlife, which allows people with limited mobility to explore designated park trails using “4WD chairs”.
You can read more about this program here.
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.
Previous editions of The Health Wrap can be read here.
