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The Health Wrap: long COVID, health finances, public sector reform – and a special song

Amid growing concerns about long COVID, the Australian Government is strangely silent on a topic that some modelling estimates will affect hundreds of thousands of Australians, at significant cost to their wellbeing, the healthcare system and workplace productivity.

In her latest column, Associate Professor Lesley Russell also shares a more upbeat note on the sounds of silence; don’t miss the very special rendition of an old Simon and Garfunkel tune, in honour of the victims of gun violence.


Lesley Russell writes:

Studies have shown that infection with SARS-CoV-2 can lead to post-acute sequelae in nearly every organ system, including an increased risk of mental health disorders.

The Washington Post recently published a good summary of what is known to date about long COVID. The lasting misery of COVID-19 long-haulers is documented here.

The costs to individuals, families and the healthcare system of long COVID are yet to be measured but will be enormous.

This past week the results of two major studies highlight two of the most serious post-infection consequences of COVID-19.

Increased risk of developing mental health problems

A large study published in the BMJ shows that people who have had COVID-19 (even mild cases) are experiencing increased rates of adverse mental health outcomes, including depression, anxiety, and stress and adjustment disorders. There is also evidence of increased risk of substance use disorders, neurocognitive decline, and sleep problems.

The results show that those who had COVID-19 were at higher risk of mental health problems when compared both to contemporaneous controls of people who were not infected but were exposed to the same stressors of the pandemic and to an historical control group from the pre-pandemic era.

Those with COVID-19 were 39 percent more likely to have depressive disorders and 35 percent more likely to show an increased risk of incident anxiety disorders over the months after infection.

They were also 38 percent more likely to be diagnosed with stress and adjustment disorders and 41 percent more likely to be diagnosed with sleep disorders.

COVID-19 patients were 80 percent more likely to develop neurocognitive problems and 34 percent more likely to develop opioid use disorders.

It is concerning that these findings come at a time when the delivery of mental health services are under enormous pressures.

It’s always informative to see what Dr Eric Topol has to say about major new findings such as these.

Heart disease risk soars

A large study published in NatureMedicine in February shows a long-term, substantial rise in risk of cardiovascular disease, including heart attack and stroke, after a SARS-CoV-2 infection. The article is here and the summary is here.

People who had recovered from COVID-19 showed stark increases in 20 cardiovascular problems over the year after infection. They were 52 percent more likely to have a stroke than the contemporary control group, and the risk of heart failure increased by 72 percent.

These risks were elevated even for those under 65 years of age and for those who lacked risk factors such as obesity or diabetes. The prevalence of such diagnoses has experts projecting a ‘tidal wave’ of cardiovascular cases related directly and indirectly to the coronavirus

Here is what Dr Topol had to say about this paper.

Where are Australian efforts to address long COVID?

To date, the Morrison Government has conspicuously failed to address this issue – or even indicate that they are thinking about them.

Professor Adrian Esterman effectively nails the issues with this article, ‘Long COVID is the elephant in the room, but it seems invisible to Australian politicians’, published last December in The Guardian.

This failure effectively demonstrates the short-term focus of this Government and its unwillingness to address the nation’s long-term societal, health and healthcare needs.

A recent briefing paper from the Deakin University Institute for Health Transformation looks at the potential scale of long COVID cases from the Omicron wave and makes some excellent suggestions for what must be done.

The Deakin paper conservatively estimates that Australia will see hundreds of thousands of people with ongoing long COVID symptoms for weeks, months and, for some people, even years. This will mean a significant burden of ill health and social and economic distress that will be costly to the healthcare system and workplace productivity.

The Deakin paper recommendations include:

  • Establish a National Long COVID Care and Support Taskforce to ensure a whole-of-government response to long COVID across the health, disability/welfare and  employment sectors of federal and state and territory governments.
  • Establish a National Centre of Excellence to oversee research, treatment guidelines and dissemination of information.
  • Establish centres to provide coordinated care and rehabilitation.
  • Ensure that the Medicare and PBS safety nets catch these patients and that they are not burdened with large out-of-pocket costs.
  • The capture and utilisation of surveillance data to ensure effective targeting of services and improved health outcomes.

As the authors note, the time for doing this is now – it cannot wait for months or even until after the election.

Meanwhile, this recent article in Nature, ‘Pandemics disable people – the history lesson that policymakers ignore’, notes that long COVID is the latest reminder that epidemics have long tails – biologically, as well as psychologically, economically and socially.

“Since the persistent effects of COVID-19 were recognized six months into the pandemic, up to 200 symptoms have been reported in 10 organ systems, including the skin, brain, heart and gut. The recurring core of these comprises loss of mobility, lung abnormalities, fatigue and cognitive and mental health problems,” says the report.

“Yet it continues to be overlooked by decision makers, who still present the costs and benefits of COVID-19 containment in terms of data on cases, hospitalisations and deaths alone. This means that in many countries, a burden of future disability is being created that could have been prevented, or reduced.”


Impact of the pandemic on healthcare spending

A new release from the Australian Institute of Health and Welfare looks at the impact of the pandemic on medical services and prescriptions. It compares MBS and PBS data from the quarter ending September 2021 with that from the quarter ending June 2021 and the September 2020 quarter.

Comparing the June 2021 and September 2021 quarters:

  • GP services have increased since the June 2021 quarter, due primarily to visits for coronavirus vaccination advice. In the quarter ending September 2021, there were 9.5 million attendances to assess a patient’s suitability for a vaccination – this was 18.4 percent of all GP attendances in the quarter, and an increase of 193.7 percent on the quarter ending June 2021.
  • The 13.8 percent increase in pathology services seen since the June 2021 quarter was driven by COVID-19 testing.
  • The number of original and repeat prescriptions dispensed at the same time rose by 16.3 percent from the June 2021 quarter to the September 2021 quarter. This rise was attributed to an increase in domestic and overseas travel, as a result of the easing of border restrictions.

Comparing the September 2020 and September 2021 quarters:

  • There was a decrease in the percentage of services delivered via telehealth consultations from 13.3 percent of all MBS services or 15.5 million telehealth consultations in the quarter ending September 2020 to 11.0 percent or 14.5 million telehealth consultations in the quarter ending September 2021.
  • A big decrease was seen in optometry services (down by 20.1 percent). This is seen as due to lockdowns which meant optometrists were generally limited to only providing essential or time critical services to patients.

There are some interesting comparisons with what is happening with healthcare spending in the United States. Most of this data is from the Peterson-KFF Health System Tracker.

In the US the pandemic disrupted healthcare spending and utilisation. In April 2020, health spending dropped precipitously as providers cancelled elective care and patients practising social distancing avoided health facilities.

Utilisation of healthcare services now remains somewhat lower than predicted based on levels before the pandemic (shown dramatically in the figure below).

Telehealth use, which soared from less than one percent of outpatient visits before the pandemic to 13 percent of outpatient visits in the first six months of the pandemic, has now declined.

Two points to note from these data from both countries:

  1. It seems that, if available, most patients prefer face-to-face consultations over telehealth.
  2. In both Australia and the United States, we are yet to see the effects of delayed and forgone care on health outcomes and healthcare spending.

Essential medicines increasingly unaffordable

The results of a survey conducted by the Pharmacy Guild of Australia (PGA) highlight the impact of rising PBS co-payments on people’s ability to buy their essential medicines.

Nearly a third (31 percent) of middle-income households ($60,000 to $100,000) without a concession card have found it difficult to afford prescription medicines. In marginal electorates 13 percent of people have gone without needed medicines because they could not afford them. Women aged 35 to 54 were the most affected.

The knowledge that a significant segment of the Australian population struggles to afford PBS medicines is not new. The ABS data show that more than 900,000 Australians delayed or didn’t get a script filled in 2019-20 due to cost.

What is shocking about this report is that it lists the medicines most likely to be skipped. These include medicines for diabetes, heart failure, Crohn’s Disease, schizophrenia, for the prevention of stroke and thrombosis, and long-acting contraceptives.

While more than six million Australians with concession cards are somewhat protected from the costs of prescription medicines, many other households and individuals must pay a co-payment that increases yearly and has more than doubled since 2000. This year the PBS co-payment is $42.50; in 2000 it was $20.60. Generic medicines can help ease the cost, but these are not always available or suitable.

It’s obvious that failure to take medicines needed to treat chronic conditions will lead to additional costs elsewhere in the healthcare system.

Will this be an election issue? It certainly deserves to be.


Reforming the Australian Public Service

As we head into election time and the focus is on policy suggestions and development (at least from the policy wonks on the outside) and election commitments (from the political parties and independents who may hold the balance of power), it’s timely to think about the capacity and capability of the Australian Public Service (APS) to detail, implement and monitor those policies and commitments.

First, some history.

In 2018 the Turnbull Government commissioned a comprehensive review of the APS, headed by former Telstra boss David Thodey. The Morrison Government received the review’s final report in September 2019. It was barely noted.

In December 2019, the Government embarked on a major overhaul of the structure, personnel and purpose of the APS, which it said “hits the theme” of the Thodey review – but did not link to any of the recommendations.

The Prime Minister was primarily concerned to ensure that there could be no intrusions of the public service into government power.

It has been clear for some time and through the findings of innumerable reports (the Thodey report was the 19th in a decade) that the APS is suffering from a lack of investment in its people, its policy development, and its digital and information communications capabilities.

As a consequence, we have seen a boom in outsourcing and the hiring of consultancies. That has generated profits for multinational corporations, but further undermined APS capability, wasted expenditure on poor value for money ventures, and weakened public service delivery.

This has been demonstrated throughout the Federal Government’s management of the pandemic and the COVID-19 vaccine roll-out.

The Morrison Government, confronted with a public service ill-prepared for big challenges and with no expertise in rolling out vaccines nationally, contracted out many aspects of the vaccine rollout to a range of for-profit companies.

As I wrote in The Conversation in July last year, companies were contracted to give overlapping advice and to provide services where that expertise already existed. The lack of transparency about how some of these contracts were awarded has also been an issue.

Late last year the Senate Finance and Public Administration References Committee released its final report on the current capability of the APS. Sadly, but not surprisingly, the report was divided on partisan lines and was described by retired senior public servant Professor Andrew Podger as another missed opportunity for bipartisan support of needed genuine reform.

The Senate report’s core recommendations were:

  1. To abolish the average staffing level (ASL) cap and require agencies to manage staffing levels within the funding provided in the Budget.
  2. For the principal mode of employment in the APS to be direct, permanent employment (with short-term peaks filled in the first instance by redeployment of permanent staff or direct employment of non-ongoing APS staff).

The Thodey report had also recommended abolition of the ASL cap – a recommendation the Morrison Government rejected. Instead, as noted above, we have seen a growing use of expensive labour hire, contractors and consultants.

The Senate report also echoes Thodey on the need to improve APS pay and conditions and notes the increasing politicisation of the service.

Last week Professor Podger produced two articles in John Menadue’s blog, Pearls and Irritations, on what needs to be done to rebuild the capability of the APS.

In Part I Podger argues that, given the Morrison Government’s response to the Thodey Report, there seems little chance for the needed reforms if it is re-elected, at least in the short-term. If Labor wins, it is important that it pursues a reform agenda that the Opposition and cross-bench can agree to.

As Podger notes – and as we have seen play out in so many ways during the pandemic – it is crucial that the APS, which serves the Government, the Parliament and the Australian public, has broad support from within the Parliament and from the Australian public.

In Part II he talks specifically to the failures of the Department of Health during the pandemic. I quote the paragraphs below in their entirety because they sum up the current situation and the need for reform so well.

“The Department seemed reticent or unable to take the lead, even in pressing agreement at the AHPPC [Australian Health Protection Principal Committee] on uniform standards regarding social distancing, isolation periods, vaccine use, tracing methodologies and testing procedures. Its expertise in pharmaceutical purchasing seems not to have been successfully used for vaccination or test kit purchasing and its aged care experts seemed reluctant to get their hands dirty working directly with residential care providers; also, the Primary Healthcare Networks did not seem to play much of a role at all, for example in working with State regional hospital networks, despite their links with GPs and pharmacies. The role the Government gave to the military also suggests a capability gap within the Department in emergency management and logistics.”

“The Commonwealth is the leader of Australia’s national health system providing the majority of funds and setting the overall policy framework including through Medicare. This leadership is not one of command-and-control but has to be earned by its own expertise and by the quality of its engagement with the States and Territories and other stakeholders, many with a considerable degree of professional and financial independence. Critical to this capability is the Department’s strategic policy capacity, a capacity that evidently has waned over the last decade or longer. That capacity is sorely needed not only to address the problems identified during the pandemic but also to address the many new challenges facing the health and aged care system: access to affordable care, the role of private health insurance, the need for more integrated patient-oriented care, quality and choice in aged care, and rising costs.”


Living with the virus in Colorado

If you follow me on Twitter, then you know that I am currently at our home on the ski slopes in Keystone, Colorado. I thought it might be interesting to write – from a public health perspective –  about what daily life is like here, in a resort village in the Rocky Mountains.

This is an area where increasingly people are living full-time or part-time to enjoy the wonderful environment and lifestyle. Summit County, which includes Keystone, Breckenridge, Copper Mountain and Arapahoe Basin ski resorts, has a population of about 31,000; 95 percent are white and 52.4 percent have a bachelor degree or higher. But it receives more than seven million national and international visitors annually.

The area has excellent health facilities and Colorado (a predominantly Democratic or blue state) has good healthcare and public health systems and a progressive governor.

Needless to say, the pandemic hit hard. In March 2020 the ski slopes were abruptly closed.

Now they are open, with caveats. Masks must be worn in indoor spaces, on the shuttle buses, and basically everywhere except on the lifts and the slopes (but they are required in the gondolas). Only those who can prove they are vaccinated can eat in the mountain food outlets and in most of these places, bookings are required.

The compliance is pretty good, although there are lots of young people who think a bandanna or a neck gaiter are the equivalents of K95 masks.

Off the slopes, mask wearing is very common in the expensive Whole Foods supermarket, less so in the cheaper City Market. Everyone is happy to use the ubiquitous hand disinfectants.

People don’t seem to be very nervous about gathering in bars and restaurants (not that we have much personal experience on this; we are mostly eating at home). These hospitality venues are supposed to require proof of vaccination, but we have seen no evidence of this.

To date Colorado (population about six million) has had 1.3 million reported cases of COVID-19 and 12,400 deaths. During the height of the Omicron outbreak in January, the state was reporting up to 15,000 cases a day. Summit County has had 9,500 reported cases and 14 deaths since the pandemic began.

Vaccination has gone reasonably well in this state (73 percent of the population aged over five is fully vaccinated with two shots) and even better in Summit County (85 percent fully vaccinated).

The state government provides free rapid antigen tests from community distribution centres and there is also free community PCR testing – although the sites are few and far between and close whenever it snows.

The increasing vaccination rate is having an impact on case numbers. On February 24, Colorado reported 374 new COVID-19 cases and the seven-day average for Summit County is now seven cases. After Sydney, that feels pretty comfortable!

What is very apparent here is the impact the pandemic has had on the workforce. Resorts like Keystone rely heavily on young people and immigrants and much of the work is seasonal. The pay isn’t great but there is employee housing, health benefits and free ski passes.

I don’t know where everyone has gone, but the local resorts lift operations are limited because there aren’t enough trained operators, ticketing offices are short-staffed, housekeeping staff are greatly reduced, and in restaurants wait staff are obviously few and new.

Everyone is advertising employment opportunities. I noticed that City Market was offering US$3/ hour over the minimum wage (US$15/hour), along with a signing bonus and a list of benefits. This is good to see, but even so it would not be easy living in these expense resort areas on that wage.

It’s telling that a local initiative that provides safe night parking and toilet facilities for employed people who live out of their cars is looking for more space so it can expand.


The best of Croakey

A daily scan of the Australian media always has some news that drives home the Morrison Government’s failures on implementing the Aged Care Royal Commission recommendations.

Recently the Federal Department of Health took the first steps towards implementing the RC recommendations by releasing a document outlining the concepts and principles which will underpin the proposed new regulatory framework.

As Charles Maskell-Knight details in an article for Croakey Health Media, this is indeed a very strange document whose status and stakeholders are not at all clear.


The good news story

It is now eleven years since former Member of Congress Gabby Giffords was shot as she campaigned in her home state of Arizona. Since then, she has faced a long, hard road back to health – a task which is without end for her and her family (her husband, former astronaut Mark Kelly, now represents Arizona in the US Senate).

She and her husband talk about that road here.

As part of her ongoing rehabilitation, she has been encouraged to return to playing her childhood instrument, the French horn.

Her efforts caught the eye of cellist Yo-Yo Ma, who then reached out to Giffords to play together.

Watch now as they rehearse Simon and Garfunkel’s ‘The Sound of Silence’ to honour the lives lost to gun violence.

Listen 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.

 

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