Tackling out-of-pocket health care costs: a discussion paper

Growing out-of-pocket health care costs are creating barriers to essential care for many Australians and arguably leading to increased hospital costs. Over time they will undermine the universality of Medicare and widen health disparities in our community. Despite this, the Abbott Government is intent on increasing Australians\u27 individual health care costs, claiming variously that the health care budget is unsustainable, price signals are needed to reduce GP visits, budget deficits must be addressed and increased funding is needed for medical research. Regardless of the validity of the Government\u27s claims, it is clear that we need to improve the way in which we manage out-of-pocket costs within our health care system. The current financing mechansims and safety-net arrangements are inadequate to ensure that growing numbers of Australians with long-term medical conditions can manage their health care costs and afford the services they need. Given the compexity of Australia\u27s health care system, with funding and service delivery responsibilities split between different levels of government and the public and private sectors, this is a wicked problem to solve. There is no silver bullet and effective solutions are unlikely to be found through simple \u27add-ons\u27 to the currentfunding system. Effective solutions are likely to be multi-faceted and will require a potent mix of evidence, ideology, consultation and leadership to be successful. To kick-start the necesary analyses, debates and policy formulations, we have developed a discussion paper on out-of-pocket costs, focusing on Medicare-funded services. The paper sets out the parameters of the problem and canvasses some promising areas where solutions may be found. Our purpose is not to dictate future policy directions but to present the current evidence and to galvanise thought, expertise and engagement to address this issue of faireness and equity

Closing the gap on Indigenous disadvantage: an analysis of provisions in the 2013-14 Budget and implementation of the Indigenous Chronic Disease Package

This paper presents the author’s analysis of the Indigenous provisions in the Australian Government’s 2013-14 Budget in the context of current and past strategies, policies, programs and funding support. It also looks at the implementation and impact of the Commonwealth’s Indigenous Chronic Disease Package. This work has been done using only materials and data that are publicly available. The opinions expressed are solely those of the author who takes responsibility for them and for any inadvertent errors. This work does not represent the official views of the Menzies Centre for Health Policy, the Australian Primary Health Care Research Institute (APHCRI) or the Commonwealth Department of Health and Ageing which funds APHCRI

Impact of the 2014-15 Federal Budget on Indigenous programs and services

Indigenous Australians will be hit hard by the 2014‐15 Budget, argues this paper. Abstract This analysis looks at the Indigenous provisions in the 2014-15 federal Budget. This is done in the light of current and past strategies, policies, programs and funding, and is supported, where this is possible, by data and information drawn from government agencies, reports and published papers. Similar analyses from previous budgets are available on the University of Sydney e-scholarship website. The opinions expressed are solely those of the author who takes responsibility for them and for any inadvertent errors. This work does not represent the official views of the Menzies Centre for Health Policy

2013‐14 Budget: analysis of health and ageing provisions

In a tough political and budget year with several major initiatives to be funded - most notably the Gonski education reforms and the National Disability Insurance Scheme, now known as DisabilityCare Australia - the health and ageing section of the 2013-14 Budget has fared reasonably well. Overall the Budget contained $43 billion in savings over the forward estimates, much of which will be funneled into these new ‘critical investments.’ Of this,$1.22 billion over five years was taken from current health programs, with the majority of this ($902 million) from Medicare.In 2013-14 the Australian Government expects to spend$64.64 billion on health, amounting to 16.2% of all Government expenses. Health spending is forecast to grow at 8.6% over the forward estimates – this is a faster rate in real terms than education (7% of spending) and social security and welfare (35% of spending).Australia gets good value for this spend. The fourth COAG Reform Council Report on the National Healthcare Agreement shows that the overall health of Australians and the quality of our healthcare system continues to improve. Life expectancy is increasing and the number of low birthweight babies and rates of infant mortality are dropping.Still, Australia’s health system faces some serious challenges. We have an increasing chronic disease burden, a growing and ageing population, rising costs of health services and technologies, and a gap that stubbornly yawns between the health of Indigenous and non- Indigenous Australians. In particular, there has been a lack of progress in prevention.The challenge for any new government post September is that too many Australians are missing out on the care they need or are not receiving the best possible care for their condition. That will require more attention to issues like equity, out-of-pocket costs and quality. We must also become more sophisticated about measurement and evaluation to ensure that we are achieving meaningful health outcomes and value for taxpayers’ dollars

Primary care and general practice in Australia

The overall health of a population is directly linked to the strength of its primary care system; a strong primary care system delivers higher quality of care and better health for less cost.  Placing primary care, as delivered through general practice and supported by Medicare, at the centre of the health care system has long been a key tenet of Australia’s health care system.  It is a major reason for Australia’s consistently high health rankings.  In a recently-released paper, Primary Care and General Practice in Australia 1990-2012: A Chronology of Federal Government Strategies, Policies, Programs and Funding (available on the Australian Primary Health Care Research Institute website http://aphcri.anu.edu.au/sites/aphcri.jagws03.anu.edu.au/files/panel/416/primary_care_and_general_practice_final_v3.pdf ), I have attempted to  summarise, from a policy and budget perspective, the way in which the delivery and funding of primary care in Australia has changed over the past twenty years. The Australian Government introduced the General Practice Reform Strategy in 1992 to overcome problems in the primary care system which had arisen as the Commonwealth retained responsibility for general practitioner (GP) services via Medicare funding and the states and territories retained responsibility for community health care funded via the Medicare block grants and their own resources. The Strategy aimed to address some specific issues facing general practice in Australia, focusing on workforce initiatives, the development of a primary care accreditation system, and remuneration strategies to more appropriately reward quality care. Funding was also committed for the establishment of the Divisions of General Practice to support GPs to work with each other and with other health professionals to improve the quality of service delivery at a local level. Commencing in 1996, an effort was made shift GPs towards a ‘blended payments’ model of funding. Initially introduced as the Better Practice Program, and subsequently reworked as the Practice Incentives Program (PIP), these initiatives were intended to allow the Government to ‘purchase’ particular quality improvement activities.  At the time there was also an intent to reduce overall financial risk to the federal health budget by increasing the share of GP funding which was capped rather than demand driven.  Over time, the PIP has evolved to include a range of outcome-based incentives, disease-specific incentives and an incentive to support practices to employ practice nurses and allied health workers.  However it has not moved the pendulum far in terms of a greater focus on health outcomes rather than the number of health services delivered. Over time, new MBS items have been introduced to improve the delivery and coordination of health services, reward bulk billing, support rural providers and to encourage the use of practice nurses and referrals for allied health services.  And alongside changes to general practice funding and the introduction of the Divisions Network, programs to address specific service gaps, for example in Indigenous health and rural health, and to educate, train and retain a GP workforce with the needed skills and geographical distribution were introduced.  As Australia looks to manage the growing burden of chronic disease and reduce health care costs and reliance on the acute care sector, there has been a focus on strengthening primary care.  GPs have a central role in determining the future use of health care resources by patients and so there has been an increased emphasis on incentives for GPs to ensure provision of the most cost-effective care possible, while maintaining quality standards.  While general practice is very successful at meeting the needs of the majority of people requiring treatment for isolated episodes of ill-health, it is less successful at dealing with the needs of people with more complex conditions or in enabling access to specific population groups that are ‘hard to reach’.  Incentives are provided to encourage care coordination, multidisciplinary care teams, after-hours care and preventive services. Under Labor, the Commonwealth Government has moved to implement reforms in the governance, funding and delivery of health care services in Australia.  A number of seminal reports have been commissioned, all of which see a greater focus on primary care and prevention as the key to improved health outcomes and a sustainable health care system into the future.  Regrettably new policy directions and the investment of resources have not always accurately reflected the recommendations of the expert advice that has been provided to the Government. Currently the Australian model of general practice falls short of the ideals of Alma-Ata: a true primary health care model requires collaboration across care providers with the creation of primary health care teams, provision for local planning and community input, an explicit commitment to equity in health care, and strategic planning across all levels of government. Recent reforms, specifically the implementation of Medicare Locals, have seen some progress towards these goals.  Indeed it can be argued that the main barrier now to full implementation of the primary health care model is the fact that responsibility for delivering and funding these services is split across the federal and state and territory governments. A significant secondary barrier is the growing rate of out-of-pocket costs experienced by patients using private services provided on a fee-for-service basis. One of the key issues that emerge from this analysis is that while, over time, many innovative and interesting new reforms and initiatives have been introduced, too often these have fallen away through lack of sustained funding, poor uptake or political changes.  There has been little or no effort to understand what worked, what did not work and why, or to measure the results in terms of economic value and health outcomes.  Investments in research in primary care and health services and analyses of data are well below what is needed.  My experience demonstrates how difficult it is to track budgets and programs using publicly available information, and begs the question of whether any of this work is done inside the bureaucracy. We need to learn from the past and implement robust and timely evaluations in the future.  Only then can we be sure that we can provide the direction and support that is needed to ensure a primary care system for the 21st century. Dr Lesley Russell is a Senior Research Fellow at the Australian Primary Health Care Research Institute at the Australian National University. http://aphcri.anu.edu.au/files/primary_care_and_general_practice_update_may_2013.pdf (link to paper mentioned above)     Photo Credit: Alex E. Proimos via Compfight c

Analysis of the Federal health budget and related provisions 2015-16

The impacts of the 2015-16 Budget must be assessed in light of the previous Budget, which casts a long shadow. ACOSS estimates that, combined, the two budgets strip approximately 15 billion / 4 years from basic services and supports that affect low and middle income households. Analysis from NATSEM highlights that the Abbott Government’s Budget changes are being g made at the expense of the less well-off and that its second Budget has done little to reverse the unfair redistributions of its first budget. The over-arching aim appears to be to improve the federal budget deficit by shifting costs off the Commonwealth Government’s balance sheet on to the States and Territories, service providers and consumers. The Health Budget this year sees the Government using the same methods to take savings with the same objectives as last year, but what leaps out is the continuing failure to develop and implement strategies and policies to underpin these decisions. Budget decisions smack of policy on the run, or in some cases, no policy at all. There is no inkling of any reformist imagination. The Government continues to find savings by using price signals (or co-payments) to reduce demand.  The controversial Medicare co-payment has been abandoned but changes to Medicare reimbursements will see patients’ out of pocket costs grow – effectively implementing co-payments by stealth. And PBS co-payments remain on the table, at least until replacement savings are found. Other common methods for achieving savings include: tightening up eligibility and funding rules for patients’ benefits and providers’ incentives; cutting funds from health programs and agencies in the name of efficiency and rationalisation; and re-negotiating agreements with service providers, including states and territories, non-government providers and the private sector. This Budget also reinforces the Government’s intent to claw back 80 billion over the next decade from the States’ and Territories’ budgets for health and education, with $57 million of this to come from funding for public hospitals. This has service to reignite the ‘blame game’ at a time when cross jurisdictional and cross sector efforts and collaborations are needed to deliver integrated care and improve efficiencies. The one substantial Government commitment is to the Medical Research Future Fund, which has become the beneficiary, even the justification, for savings from many areas in the Health portfolio. It is ironic that these program cuts will quickly lead to impacts on the health of individuals and the population as a whole – the very things that the MRFF is lauded as addressing through the research it will support

Stable Aqueous Nanoparticle Film Assemblies with Covalent and Charged Polymer Linking Networks

The construction of highly stable and efficiently assembled multilayer films of purely water soluble gold nanoparticles is reported. Citrate-stabilized nanoparticles (CS-NPs) of average core diameter of 10 nm are used as templates for stabilization-based exchange reactions with thioctic acid to form more robust aqueous NPs that can be assembled into multilayer films. The thioctic acid stabilized nanoparticles (TAS-NPs) are networked via covalent and electrostatic linking systems, employing dithiols and the cationic polymer poly(l-lysine), respectively. Multilayer films of up to 150 nm in thickness are successfully grown at biological pH with no observable degradation of the NPs within the film. The characteristic surface plasmon band, an optical feature of certain NP film assemblies that can be used to report the local environment and core spacing within the film, is preserved. Growth dynamics and film stability in solution and in the air are examined, with poly(l-lysine) linked films showing no evidence of aggregation for at least 50 days. We believe these films represent a pivotal step toward exploring the potential of aqueous NP film assemblies as a sensing apparatus

Differences between murine arylamine N-acetyltransferase type 1 and human arylamine N-acetyltransferase type 2 defined by substrate specificity and inhibitor binding

Background: The mouse has three arylamine N-acetyltransferase genes, (MOUSE)Nat1, (MOUSE)Nat2 and (MOUSE)Nat3. These are believed to correspond to (HUMAN)NAT1, (HUMAN)NAT2 and NATP in humans. (MOUSE)Nat3 encodes an enzyme with poor activity and human NATP is a pseudogene. (MOUSE)Nat2 is orthologous to (HUMAN)NAT1 and their corresponding proteins are functionally similar, but the relationship between (MOUSE)Nat1 and (HUMAN)NAT2 is less clear-cut. Methods: To determine whether the (MOUSE)NAT1 and (HUMAN)NAT2 enzymes are functionally equivalent, we expressed and purified (MOUSE)NAT1*1 and analysed its substrate specificity using a panel of arylamines and hydrazines. To understand how specific residues contribute to substrate selectivity, three site-directed mutants of (MOUSE)NAT2*1 were prepared: these were (MOUSE)NAT2_F125S, (MOUSE)NAT2_R127G and (MOUSE)NAT2_R127L. All three exhibited diminished activity towards “(MOUSE)NAT2-specific” arylamines but were more active against hydrazines than (MOUSE)NAT1*1. The inhibitory and colorimetric properties of a selective naphthoquinone inhibitor of (HUMAN)NAT1 and (MOUSE)NAT2 were investigated. Results: Comparing (MOUSE)NAT1*1 with other mammalian NAT enzymes demonstrated that the substrate profiles of (MOUSE)NAT1 and (HUMAN)NAT2 are less similar than previously believed. Three key residues (F125, R127 and Y129) in (HUMAN)NAT1*4 and (MOUSE)NAT2*1 were required for enzyme inhibition and the associated colour change on naphthoquinone binding. In silico modelling of selective ligands into the appropriate NAT active sites further implicated these residues in substrate and inhibitor specificity in mouse and human NAT isoenzymes. Conclusions: Three non-catalytic residues within (HUMAN)NAT1*4 (F125, R127 and Y129) contribute both to substrate recognition and inhibitor binding by participating in distinctive intermolecular interactions and maintaining the steric conformation of the catalytic pocket. These active site residues contribute to the definition of substrate and inhibitor selectivity, an understanding of which is essential for facilitating the design of second generation (HUMAN)NAT1-selective inhibitors for diagnostic, prognostic and therapeutic purposes. In particular, since the expression of (HUMAN)NAT1 is related to the development and progression of oestrogen-receptor-positive breast cancer, these structure-based tools will facilitate the ongoing design of candidate compounds for use in (HUMAN)NAT1-positive breast tumours. </p

Effect of increasing fruit and vegetable intake by dietary intervention on nutritional biomarkers and attitudes to dietary change : a randomised trial

This work was funded by The Scottish Government Rural and Environmental Science and Analytical Sciences Division (RESAS) and supported by the Rank Prize Funds.Peer reviewedPublisher PD

Reopening schools during the COVID-19 pandemic: governments must balance the uncertainty and risks of reopening schools against the clear harms associated with prolonged closure.

Evidence to support the effectiveness of global school closures in controlling COVID-19 is sparse. There is continued uncertainty about the degree to which school children are susceptible to and transmit COVID-19. Balancing the potential benefits with harms involves explicit trade-offs for governments, but there has been little recognition that low-income and middle-income countries face a very different set of trade-offs around school reopening from those in wealthy countries