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The Health Wrap: tackling disparities, a big question, costly healthcare, and more on Emergency Departments

The Health Wrap covers important health issues that you may not hear discussed in depth by the mainstream media or politicians during the federal election campaign – but should.

For a refreshing change, Associate Professor Lesley Russell also brings a good news story about the environment.


Lesley Russell writes:

For political junkies and policy wonks and everyone who cares about good election outcomes that improve the lives of all Australians, it’s been a busy, crazy and pretty unedifying start to the election campaign.

But alongside all the election nonsense, nasties and just a few memorable moments, life goes on and so does The Health Wrap.

There are no election stories here (well, maybe just a mention or two) – just stories about what could be or should be election issues.

To follow election commitments and expert commentary on these, make sure you head over to the weekly edition of The Election Wrap, check out the regularly updated #AusVotesHealth2022 Election Scorecard and bookmark this link for Croakey’s wider coverage of health and the election.


Tackling the Emergency Department crisis

Emergency Departments under pressure and the related problem of ambulances unable to unload patients (referred to as “ramping”) are not new concerns, but the situation has worsened since the pandemic began.

It leads to media stories like this in The Age about patients waiting for attention and beds in hospital corridors for hours longer than should be the case.

The release of reports on waiting times for emergency care issued regularly by the Australian Institute of Health and Welfare (available here) and various state agencies always serve to generate a rash of media stories and commentary.

Arguably it was these issues that helped bring down the Liberal Government in the recent South Australian election; having highly functional EDs in their community is clearly a priority for voters.

This is a wicked problem that is about much more than dollars and staffing levels and as such it requires a multifaceted solution (or maybe it should be solutions). The situation is complicated because there are so many myths and so much dogma surrounding problems with Emergency Departments – which are not called that for nothing!

The NSW Agency for Clinical Innovation has assembled a great collection of “myth-busting” papers.

While the Australian Medical Association (AMA) always seems to be the loudest professional voice on this topic (and, in fairness, the AMA report cards are a succinct and valuable resource), more attention should be paid to those at the coalface – the emergency doctors and nurses and the paramedics.

The Australasian College for Emergency Medicine (ACEM) , the College of Emergency Nursing Australasia (CENA) and the Australasian College of Paramedicine (ACP) are key stakeholders. The ACEM website has excellent materials outlining recommendations for tackling access block (which is described as “the single most serious issue facing hospitals”) and the College’s election priorities.

It is gratifying to see how ACEM positions look more broadly at the need for whole-of-system reforms.

This detailed diagram (courtesy of Dr Simon Craig) makes it very clear why that is the case (see a bigger version here).

In an article for Croakey Health Media written in January 2020 that responded to a series of Croakey articles describing the problems from the perspectives of patients, carers and clinicians, ACEM President Dr Clare Skinner outlined her wish list for health systems improvements.

That list of ten items is still very pertinent for those intent on improving the situation. And the file of Croakey stories on this topic (it can be accessed here) has also grown since then.

Too often when addressing these complicated issues around the organisation and delivery of emergency care, the needs of patients and their families and carers, as they face situations that are often life-threatening and always worrying, are ignored. In such situations expectations for care are heightened.

This is particularly the case for patients with acute mental illness. The Safe Haven at St Vincent’s ED in Melbourne is a great example of addressing this issue in a compassionate way.

Research shows that more must be done to improve cultural safety for Aboriginal and Torres Strait Islander people in EDs.

Federal Labor has made a major election commitment for a trial program to set up 50 urgent care clinics as an effort to divert some demand for low-acuity care away from EDs. This has been relatively well received as a step in the right direction (see also this media release from the ACP) but, as my Croakey colleague Charles Maskell-Knight writes, even this relatively simple initiative faces implementation challenges.

I only recently discovered that back in early February Health Minister Greg Hunt announced a funding round of up to $24 million in research to improve acute care systems and reduce waiting times in hospital EDs.

Up to $3 million will be provided for the top research proposal in each state and territory, for medical research and innovation projects that “develop and implement evidence-based, scalable clinical models of care to improve acute care and reduce pressure on Australia’s EDs”.

Successful projects are due to be announced in early May. Let’s see what happens with these.


A big question

Hospital reforms must confront the big question – the role of Private Health Insurance.

Amid professed concerns from the Coalition about the economic sustainability of Medicare, the Pharmaceutical Benefits Scheme, and the NDIS, one growing impost on the health budget – the more than $7 billion spent every year on the Private Health Insurance Rebate (PHIR) – is never held up for scrutiny by the Morrison Government

The PHIR is the epitome of a robbing Peter to pay Paul system (taxpayers’ dollars are used to reward those who purchase PHI and thus jump the queues to access surgery on the basis of economic status rather than health need).

The purpose of the rebate was to increase private health insurance membership to reduce public hospital pressure. A recent article in The Conversation, also republished at Croakey, suggests that, on these measures, it seems to have failed. Indeed, it may have served to increase public hospital waiting lists.

The pandemic has highlighted the central role of the public hospital system and Australians’ trust in the public system. So (once again), there is a call to re-invest these billions of dollars in shoring up public hospitals and their workforce.

The total cost of the PHIR is considerably more than $7 billion annually – in addition to the direct subsidy, there is another $6 to $7 billion annual budget cost from the tax concessions to encourage high income earners to take out PHI. So there’s potentially enough dollars here to both boost the federal contribution to public hospitals and begin the process of including dental care within Medicare.

The pandemic, combined with decreasing numbers of Australians choosing to forego private health insurance, has decreased the use of private hospital services and subsequently increased the financial pressures on for-profit private providers.

In an article for MJA Insight, Dr Aniello Iannuzzi postulates that, with the rising cost of living and stagnant wages, Australians will continue to jettison PHI, and private hospitals will offer fewer services to remain viable.

This outlook ignores the fact that there will always be a significant number of people who will choose to purchase private cover, even in the absence of a rebate, and others who will choose to self-insure and cover the costs of their private care when they feel this is necessary.

The relationship between the PHI funds and private hospitals has always been fraught. Australian governments have consistently avoided defining the roles of PHI and private hospital care since Medicare was first introduced, despite the fact that Medicare pays out some $3 billion a year for private hospital services.

More recently, there have been clashes over issues such as the costs of medical devices. And now Iannuzzi reports that the funds have made a $2 billion windfall during the pandemic as people have had to forego elective surgeries and other medical procedures.

With as much as $17 billion of taxpayers’ dollars going to support a private system that is not even available, let alone affordable, for many Australians, on top of what is paid to the Medicare Levy and in out-of-pocket costs, it is time to look at the finances and make some tough decisions.

This includes answering a fundamental question: what is the purpose of private hospital care?

At the very least we could hope that current financial pressures in the private sector, over-crowding in public hospitals, the increasing need for medical training slots, and the lack of sub-acute beds will help to drive a better, more efficient integration of public and private sectors.


Data matters

More data is needed on social determinants of health if inequities are to be addressed.

A recent paper from Professor Fran Baum and colleagues published in The Medical Journal of Australia makes the case that Australian needs better data on health inequities to support building back fairer from the pandemic.

Australia has a large number of health data sources, but – as the Australian Institute of Health and Welfare regularly points out – critical information is lacking in a number of areas, especially for Aboriginal and Torres Strait Islander peoples, migrants and refugees, people with disabilities, and those from across the gender spectrum. These gaps limit the monitoring of social determinants of health and their impact on health equity, which means that research, policies and programs and funding cannot be effectively targeted to address inequities.

Baum and colleagues point out that, in 2012, the Senate Standing Committee on Community Affairs held an inquiry on Australia’s response to the World Health Organization’s Commission on Social Determinants of Health report “Closing the gap within a generation” and noted significant gaps in data on the social determinants of health. In the decade since, little has been done at the national level to remedy this.

The Senate report from this inquiry made a number of recommendations that remain applicable today. These include:

  • That the government adopt administrative practices that ensure consideration of the social determinants of health in all relevant policy development activities, particularly in relation to education, employment, housing, family and social security policy.
  • That the government place responsibility for addressing social determinants of health within one agency, with a mandate to address issues across portfolios, and that this body is required to make an annual progress report to parliament on its work.
  • That the NHMRC give greater emphasis in its grant allocation priorities to research on public health and social determinants research.


Addressing the “disease of disparity”

It’s a neat segue from the above report on the need for more and better data about the social determinants of health to exploring the advice offered in a report from the UK about how such data might best be used.

The Progressive Policy Think Tank has developed “The disease of disparity: A blueprint to make progress on health inequalities in England”.

It argues that the scale of health inequality was a key reason the UK lacked resilience when COVID-19 struck, and provides what is described as “a constructive plan to tackle the ‘disease of disparity’ in England – and to achieve the health, social and economic gains possible from addressing health inequality”.

It identifies six areas where NHS policy incentives are misaligned with an ambition to tackle health inequality:

  • The narrow focus on limited output-measures, such as GDP
  • Chronic short-termism in policymaking
  • A lack of effective cross-government working on health
  • The NHS structure
  • Priorities and definitions of success in the NHS
  • The NHS’ centralised approach to health policy.

I think, with only very slight variations, we could say this about Medicare in Australia.

The report then makes six recommendations for addressing these problems:

  1. Increase the amount of NHS funding in the most deprived parts of the country alongside a specific, achievable and measurable target on inequality for every clinical priority in the NHS Long Term Plan.
  2. Pilot the countrywide scale-up of community/neighbourhood hub models of care delivery that provide a ‘one-stop shop’ for health, social, financial, emotional and spiritual need – with NHS, local authority, religious, charity and social prescribing services co-located within an accessible community setting. This model should include an increase in the number of link workers and care navigators.
  3. A fund to develop community health assets, supporting public health and the development of flourishing ‘health economies’ allocated across the country.
  4. Move to a wider dashboard of measures of prosperity, supplementing measures like GDP, with the ONS’ new Health Index as a measure of prosperity. This should see the Health Index reported on at budgets, spending reviews and fiscal statements.
  5. The introduction of health impact assessments across national and local government to measure the impact of new policies and major spending decisions on population health.
  6. The UK government should introduce a public health budget, allocated at five percent of total health expenditure in the first instance, modelled on the New Zealand Wellbeing Budget and tied to the Health Index. This would ensure funding and opportunity for long-term focussed policy and investment decisions, based on improving health.

How could these recommendations play out in Australia?

Regarding Recommendation 1: In Australia we make virtually no effort to do this; indeed areas of deprivation are generally less well served by the healthcare system. The lack of data for Closing the Gap targets highlights the problems in measuring efforts to address health inequality.

Regarding Recommendation 2: This means more Community Health Centres and ACCHO-style models of care.

Regarding Recommendation 3: In Australia this should be a role for a revived National Preventive Health Agency and/or Centre for Disease Control.

Regarding Recommendations 4-6: There must be greater awareness of the role of the Social Determinants of Health and of how decisions made about the minimum wage and welfare supports, environment and climate change, transportation, mining, education, housing, human rights and social justice impact the health, wellbeing and resilience of individuals and communities. Australian political culture must change so that funding for health, healthcare, aged and disability care and welfare is seen as an investment in national productivity and wellbeing rather than a budget impost.

As far as I can determine, this report has made little public impact in the UK (where politicians are presumably too busy dealing with Boris Johnson’s partying proclivities). But sooner or later Westminster must come to grips with these issues (as must Australian governments).

In December the final report on progress to address COVID-19 health inequalities was delivered and a government response is expected shortly to the report of the Commission on Race and Ethnic Disparities (released in March).

The response is expected to include actions to address the longer-term health inequalities which were a contributory factor to the disproportionate impact COVID-19 has had on ethnic minority groups.


A study on specialists’ out-of-pocket costs

A new paper highlights how patients’ out-of-pocket costs to see a specialist doctor vary depending on which of a doctor’s several offices they make their appointment. What does this mean for efforts to address the barrier these costs represent to patients’ ability to get the care and treatment they need?

The paper, from Professor Adam Elshaug’s group, is published by the Australian Health Review. It’s frustratingly behind a paywall, so I’m grateful for @AElshaug tweeting out the findings. See his Twitter thread here.

The researchers looked at the billing practices of cardiologists, ophthalmologists and oncologists, the majority of whom had at least two practice locations. They found that cardiologists had a median of three different costs for patients per location and ophthalmologists had four. In contrast, oncologists had only one cost and 57 percent bulk billed.

We can assume this means that these specialists are aware that for some patients the OOP costs are a significant burden and they adjust their charges in response to this. It’s potentially more problematic if someone skips an appointment with an oncologist than an ophthalmologist, which may explain their higher bulk billing rate.

But as Elshaug points out, the doctors who bulk bill a significant proportion of their patients may  also charge some of their patients a fee that means substantial OOP costs.

It’s pretty shocking to see that a visit to a cardiologist can cost almost $100 more than the Medicare reimbursement and that some oncologists’ fees mean an OOP cost of close to $150.

Elshaug suggests in his tweets that a transparent approach to patient information about doctors’  fees requires the availability of a doctor’s complete fee list for a service. As the paper concludes:

“Summary statistics on price transparency websites based on a single amount (like a median or mean OOP charge) might mask substantial variation in costs and lead to bill shock for individual patients.”

An article just out in The Guardian (Calls for GP funding boost as figures reveal how Medicare gap hits some of Australia’s poorest areas | Health | The Guardian) has a breakdown of OOP costs for a standard (15 minute) GP consult by electorate. The new data reveal that some of the most disadvantaged electorates have among the highest average OOP costs for a consultation.

Somehow every time the Health Minister touts the bulk-billing statistic for GP services he manages to ignore that fact that those Australians who are not bulk-billed are increasingly paying more. This despite endless fact-checking to remind him that his delight in this figure is misplaced.

The average OOP cost for a standard consultation is now $41.05. In places like the Northern Territory and western Sydney, it rises to over $50.

Medicare funds a rebate of $39.10 for a standard consultation and aside from indexation rises, this amount has been frozen since 2013. Increasingly GPs are doing what my GP does – after more than 30 years of bulk-billing everyone, the practice will is now only bulk-billing children, pension card holders and those in need.


Real reforms needed for mental health

The Morrison Government makes a big deal about its investment in the National Mental Health and Suicide Prevention plan ($2.3 billion in the 2021-22 Budget and $648.6 million in the 2022-23 Budget) delivered in response to the report from the  2020 Productivity Commission inquiry.

But as Sebastian Rosenberg points out in a post-Budget article for Croakey Health Media, this level of spending falls well below what is needed: mental health disorders make up 12 percent of the burden of disease but federal spending is on mental health is only five percent of the healthcare budget and only 7.5 percent of the total health budget. One in five Australians experience a mental health condition in a given year.

There’s a growing mental health crisis fuelled by the consequences of the pandemic, a series of major natural disasters and worries about climate change and family finances – all aggravated by the inability of many to gain timely and affordable access to appropriate care and treatment.

An ABC News report from September last year found that psychologists were reporting waiting times of four to six months for new patients.

A new poll commissioned by Orygen, the youth mental health service, reveals mental health is a top election priority for voters. The poll found only one third of voters thought access to mental health treatment for young people was good. In contrast, 73 percent and 60 percent of respondents respectively felt access to GPs and dental care was good.

In an article in response to the poll results, mental health experts offered three actions to address the current crisis:

1. Provide community services for people who fall into what is called the “missing middle”.

This was a recommendation from the Productivity Commission. These are people who fall through the cracks because their mental illness is too severe to be treated by a GP, a headspace centre or 20 Medicare-subsidised sessions with a mental health professional but who are not sick enough to qualify for state-funded crisis mental health services.

Many youth centres have been described as a front door to nowhere because they cannot provide the services their clients need.

For many of these people alternative services, such as private psychiatrists or private hospitals, may be inaccessible because of long waiting lists or very high out-of-pocket cost

2.     Develop a nationally coordinated mental health waiting list that would enable regional responses.

I was shocked to discover that there is currently no way to measure who is waiting for mental health services, how long they have waited, and whether the services they finally receive are the right ones.

3. Increase the mental health workforce.

Australians for Mental Health is calling for the capacity of this workforce to be doubled, including psychiatrists, psychologists, digital services and peer workers who are employed because of their lived experience of mental illness.

The University of Sydney’s Sydney Mental Health Policy Forum has just released its paper on options for mental health reform in Australia.

This sees accountability as the key area for change, stating that Australia needs an independent mental health commission with teeth, to set goals and targets along with  a dedicated ‘observatory’ to gather and report on progress and the consumer experience of care, in real time.

As Croakey’s Election Report Card shows – to date the major parties have made no move to improve these key issues.

As I was working to edit this edition of The Health Wrap for publication, I read the weekly update from Leanne Begley, the CEO of Mental Health Australia. I think her comments about the mental health provisions in the Budget are spot on:

So, not only is it clear that the 2022-23 Budget will not address the Productivity Commission’s recommendations, it does not provide a strategic national vision for mental health and furthermore it is also clear that it is not enough to shift mental health’s percentage share of the global health budget.

In fact, investment in mental health via the Australian Government appears to be developing a bad habit of sporadic large investments followed by years of under-investment, which deteriorate the sector to the point where another large investment is required. At least, that is the picture painted by a decade or so of budget announcements.”


The best of Croakey

Read the article: Major parties suffer from a climate credibility gap: new health election scorecard.


The good news story

I’m a Big Ernest Shackleton fan and have a whole library shelf devoted to books about the amazing survival of the Shackleton Antarctic expedition. You may have read that recently his ship (the aptly named “Endurance”) was found under the pack ice in the Weddell Sea.

Shackleton saved his crew with a miraculous voyage in a small lifeboat to remote South Georgia Island, which used to be a whaling and sealing station. It’s an island with no permanent human population but it was once over-run with introduced invasive species including rats and reindeer.

The New York Times has the good news story (with some amazing photos) about how the invasive mammals have been eradicated and the island and its sea and bird life are experiencing a remarkable ecological recovery.

Strangely, this is occurring at a time when climate change is pushing back the glaciers on the island, so I guess the long-term future of this good news story remains to be told.Read the article: Abundance, Exploitation, Recovery: A Portrait of South Georgia.


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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