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It’s time to switch on to a new health debate

Wednesday, 21 May 2008

Health journalist Melissa Sweet writes:

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Since the budget, the AMA and private health funds have done an excellent job of capturing the health debate. If you believed the spin, you’d think the public health system was about to collapse.

Here at Croakey, we’re starting a campaign for an alternative health debate. We want to know what you think are some of the big issues that we should be talking about in health.

We’ve made a few suggestions: whether the way we fund and organise primary care needs a major overhaul; whether fee-for-service medicine has a future; and what can be done to empower local communities and services to create their own solutions to some of their health problems.

This has happened at Coffs Harbour, where the local area health service and division of general practice have collaborated in setting up a refugee health clinic. It’s happened at Tennant Creek which has begun training its own nurses, thanks to an unusual joint venture between the health and education sectors.

And it’s happened in the border cities of Albury-Wodonga, where cancer patients have gained better access to a wider range of services in recent years. These gains gave occurred thanks to collaboration between the private, public and community sectors.

Do you know of other such examples? And what do you think of the current health debate?

What issues would you like to see hitting the headlines in health?

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Jennifer Doggett Wednesday, 21 May 2008 2:18:07 PM: Hear, hear! Despite the rant from the private health funds and the AMA there is no evidence that changes in private health insurance numbers have a significant impact on the public hospital system. It is also a fallacy to equate PHI with the "private health system", PHI is only one (not very efficient) way of funding private health services – there are many other ways in which private health can (and is) funded. Lets drop our obsession with PHI – which after all is responsible for only about 7% of total health funding – and focus on the health issues that really matter: access, equity, quality and efficiency.
Gavin Mooney Wednesday, 21 May 2008 2:35:58 PM: The current health debate (as usual) is all about money and mechanisms. What we need is an open publc debate involving the people whose health is at stake - the citizens of Australia. Not, about the relative minutiae of whether they want the Medicare threshhold changed or the 30% tax rebate changed but big picture stuff. Do they want choice or equity? Do they want to leave health to the vagaries of the market place or do they care about the health of the disadvantaged such as Aboriginal people? Do they want more emphasis on hospital care or on primary care and community care? Is treatment more of a priority than prevention? Inforrmed randomly selected Aussies in citizens' juries in my experience go for the seond choice in each instance. Let's not have the debate on health care about the detail until we get the principles sorted out. The citizens are the only people who can legitimately do this. The AMA and the private health insurers have their own vested interests which is why they are crying so loudly now. I defend their right to make their case but why should we listen to them? The government wasn't elected by these bodies but by the citizens. Whose health is it anyway?
pamela Wednesday, 21 May 2008 2:57:27 PM: We cannot afford the present system and if we keep trying we will kill off one of the best health care services in the world. Overservicing is just one area. My elderly relative in a hostel is visited 2/3 times per month at $80 a pop- why. She was on an eye specialist merry-go-round every 3 months -full eyetesting etc $180 a visit- no reason. At my local community health centre I am not called back in person(and pay) to receive results easily given over the phone. So many ways that costs are bumped unnecessarily. We can do better with primary health care using nurses as well as doctors and teaching people to make good decisions about their health.
Irene Fisher, Sunrise Health Service, Katherine Wednesday, 21 May 2008 4:13:59 PM: There is no doubt in my mind that if you invest more in primary health care, you will reduce the need for expensive secondary interventions. If there is to be improvement in health, people must have ownership of the solutions to their problems. Models developed in indigenous community controlled primary health can be adapted to mainstream Australia - you just have to redefine your "community".
Miriam Lyons, Centre for Policy Development Wednesday, 21 May 2008 5:35:13 PM: I have to confess that right now, I'm one of those people who are 'narrowly focused on health financing'. But I have an excuse. I've been in the U.S. for the past week. Unless you've been inoculated against politics it's hard not to succumb to the national contagion - griping about about the health system, which here is synonymous with griping about private health funds. In contrast to Australia, the top complaints here aren't about long waiting lists for elective surgery, or how hard it is to find a doctor who bulk-bills. They're from middle class people ruefully shrugging their shoulders about the fact that they couldn't get insurance to cover the gap between when their last contract ended and the the next one begins, leaving them at risk of bankruptcy if they're unlucky enough to need hospital in the meantime (http://www.drummajorinstitute.org/library/article.php?ID=6580). They're from people who are sick of haggling with their insurer over every single medical bill, and constantly having to justify their doctor's choice of treatment to an all-powerful HMO. They're from small business people who are struggling to pay their employees' skyrocketing insurance premiums (http://businessforsharedprosperity.org/Health+Care/Small+Business+Majority). And from the wonks and economists, who are worried that the supposed 'safety nets' for the poor have ended up costing as much per capita as most countries spend on their universal schemes. From this side of the Pacific, watching Clinton and Obama attempting to construct a politically viable escape route from this mess, it's clear that if you get health finance wrong, it's pretty hard to get the health system right. The good news is that the right funding model - based on principles of universality, equity, efficiency and subsidiarity, should make it easier to deliver the kind of seamless, patient-centred care that you're talking about. It should redirect power away from the nanny state and the nanny corporation and towards communities and consumers - enabling them to choose, for example, between fee-for-service or salaried GPs. It should become a tool for combining the responsiveness and innovation of local control with the the efficiency and equity of a single payer and national standards. Perhaps the sign of a good health finance system is that no-one talks about it very much. I look forward to the day when I can stop talking about it in Australia!
garyb Wednesday, 21 May 2008 9:05:33 PM: surely the age related premium increases for over 31Y.O must contribute to the attitude of can pay, but, won't play. now the penalty threshold has been removed, it is very clear most can gamble that several thousands a year placed elsewhere is better value than services not needed. in 30 years i have not had a claim for HBA..when i did go to hospital the likely gap was so large i went as a public patient for no cost! as advised by the hospital staff, just do not mention the private cover. health insurance is not insurance, it is a means of profit making subsidised by successive federal governments. let people decide, the health funds will collapse and a different better funding scheme will emerge. several billions profit last year during the time of highest premiums and subsidies is a recipe to go extinct. the public knows a rort when it sees one.
Mary Ann Thursday, 22 May 2008 12:27:28 AM: Many people do not use their Private Health Insurance when they are admitted to hospital because they fear the extra charges they may have to pay to health service providers. The Private Health funds have made outrageous profits from this fear because patients contribute but do not make claim for reimbursement. Some public hospitals do not charge patients who are admitted as Private Health contributors. Works out better for the patient because there are no extra charges and the hospital bills the Health Fund for reimbursement of costs. I wonder how the Health Funds like the arrangement.
Rod MacQueen Thursday, 22 May 2008 10:53:01 AM: I agree with everything you say, Melissa. My experience over the last 15 years in 3 states is exactly as noted – that good health care too often occurs despite the system, rather than because of it. Endemic generic managerialism with its incapacity to even recognise good versus mediocre (or occasionally, downright bad) health care plays a big part here. Good clinical care is about risk balance, and there is rarely certainty in managing complex conditions in complex people. But today’s managers need certainty, so risk is not acceptable – in practice this means clinical care of complex problems is thus not possible in their model. It is interesting that when locals get together and become focussed upon services delivery, instead of clean lines of accountability (or plausible deniability), then the service can develop, there are people willing to do the work, and outcomes can improve. But there are risks with incurring the wrath of the existing power holders, including uncertainty of funding. I hope this is an issue the Commonwealth can address – but as noted, the debate still seems to be stuck on hospital funding. Most of us desire to stay out of hospital, and the impact of hospitals on population health is miniscule. Oh, except for the fact that hospitals consume most of the health dollars. What about a better primary care service that keeps people out of hospital? One of the strengths of working in small communities is that we can often find out how a disaster arose – I think of helicopter evacuations and days in intensive care because impulsive (and intoxicated) people are given cardiotoxic tricyclic drugs to shut them up – not once but at least 3 times. Total cost, tens of thousands, to say nothing of people nearly and completely unnecessarily dying! Is this kind of issue taken seriously. Even from an economic point of view? Not in my experience. Ten minute fee for service consultations will never be able to address complex comorbid health issues. This structure actually rewards poor management because people keep coming back for more (usually unnecessary) tests and more (almost always unnecessary) antibiotics, or whatever. Ironically, the poor customers often say “the doctor tried so hard” or some such pap. We need better than this. The Extended Primary Care Medicare items attempt to address this issue, at least by removing a disincentive to longer consultations, but I fear too many of my colleagues have fallen into the quickie consultation model for this to have much impact. Local collaboratives seem like a good start to resolving some of these problems – 160 years ago, Rudolf Virchow noted that medicine was a social science and that “the physician is the natural attorney of the poor”, a comment as relevant today as it was then. Let the concerned clinicians drive the change on behalf of their patients!
Moira Smith Friday, 23 May 2008 4:25:16 AM: Dental care is primary care. Oral disease can affect the whole body, never mind the direct pain and inconvenience it causes. Here in Australia, if the media are to be believed, we have a lack of available dentists - and when the dentists are available, according to my information, many people can't afford the fees. Even with private health insurance, going to the dentist is an expensive proposition. Those who can't afford private care (pensioners, usually) can wait years to be seen in a public dental clinic while their problem gets worse. Putting dentistry in the Medicare system could be expensive in the short term but in the long term could reap dividends.
Gary Sauer-Thompson Saturday, 24 May 2008 5:56:53 PM: I would like to defend the insight into the Medicare thresholds levy debate of Melissa Sweet. The debate is framed thus; the defenders of private health insurance industry (AHIA and AMA ) say that the large numbers of people (the numbers vary from 400,000—900,000 depending on whose research is used ) dropping out of private health insurance will place enormous pressure on an already over loaded public hospital system The Rudd Government counters by saying that their increased in public hospitals to reduce queues and improve the quality of care will enable the public hospital system to cope with increased demand. Melissa‘s insight is that the debate is flawed because primary care is not in the picture. Health has been reduced to acute care in hospitals. Putting primary care into the picture allows us to see that the fit and healthy singles who have dropped out of private health insurance would go to their local GP or allied health professional when they became unwell or sick, rather than the emergency department of a public hospital. Primary health care functions to keep people out of hospital, and if it is to do its job well, then it needs increased investment to become more innovative to provide multidisciplinary care for chronic lifestyle diseases and illness. Stephen Leeder argues that what drives changes in health care is a demographic shift as an ageing Australia will alter the politics of health care. But this shift will require greater investment in primary care as the emphasis will be on keep an ageing population mobile, active and alert to prevent them from having falls and ending up hospital. This requires a transformation in primary care as the services of allied health care professionals will be need to keep the bodies of older Australia flexible and their minds alert. The age of gerontology is the age of allied health care. That means a fundamental rethink of how we deliver primary care in 2020 Australia.
Neil Rolley Friday, 30 May 2008 10:37:56 AM: I read a lot about primary health care, but do not know what it means....am reasonably well educated (BE mech and elec), and could someone write a few words describing the meaning ...Regards Neil Rolley

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It’s time to switch on to a new health debate

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