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Category: Medicare

29/03/2025

2025 March Budget Response

27 March 2025

Warning. This is a long post, with my opinion followed by a more detailed analysis from Zali Steggall.

Treasurer Jim Chalmers has now brought down his March pre-election budget.

All the noise is about the few sweeteners, the $150 electricity rebate (paid to the companies that are maintaining the prices), and a very modest tax cut, coming in the future, and perhaps not even enough to overcome bracket creep.

In the nine and half page analyses in the SM Herald the next day, not one got down to any sort of real discussion of the details. Ross Gittins summed up the situation best with his closing comment, ‘This government is timid, uninspired and uninspiring. This budget fits it perfectly’.

To look in more detail, I got an email from Zali Seggall, the Teal from Warringah, a barrister and ex-Olympic skiing medallist who defeated Tony Abbott, the then Prime Minister to win the seat. She at least had done her homework, though she skirts some of the bigger issues that might be politically sensitive for her, as she also faces her conservative electorate in a few weeks.

If the standard to measure budget is what needs to be done, it is quite a poor budget, mostly just business as usual with only little tinkering, but that has been the whole approach of the Albanese government, and why the Greens are rising on the Left of the Labor Party, and the Teals are rising on the left of the Liberal Party.

There is minimal for Climate Change, dwarfed by the subsidies for diesel fuel and the fossil fuel lobby.

There is no discussion of tax reform, though negative gearing and the capital gains tax concession is responsible for the huge amount of ‘investment’ in property speculation, which also raises rents and means that poorer people cannot get Housing. This also affects domestic violence as women have nowhere to go, crime and kids unable to start a family. Research gets little, and the National Anti-Corruption Commission and Australian Electoral Reform Commission to stop electoral disinformation is similarly neglected. Defence has a tiny increase presumably to please Trump, or try to remedy the fact that the US cannot be relied upon, but the huge issue of the AUKUS submarines is not addressed in the Budget, nor by Zali. Aged Care needs a lot of policing as do many privatised industries. Medicare will supposedly be revived, but they are still having trouble recruiting GPs and nurses. No prizes for guessing why. The government has had control of the wages and rebates and has simply let them fall against inflation. There has been some tinkering with Medicare, but the GPs and nurses remain unconvinced.

But if you think that Labor was poor on policy, you need to think about the Liberal’s effort in reply on 27th. Dutton wants to lower the petrol temporarily. This will naturally favour commuters with big cars in outer suburban marginal electorates. It will also be bad for Climate Change and delay electrification of the car fleet. He wants to solve the energy crisis by producing more gas by fracking NSW (sorry environment again), sack 40,000 public servants (about half of Canberra’s public servants, who will presumably be replaced by private consultants at twice the price), and of course his nuclear policy for expensive electricity in never-never time. (We need not mention that the coming large-scale renewables need supplementation that can be turned on and off, and nuclear does better at producing a constant flow).

But since the new politics seems to be that you criticise your way into power, perhaps he has a chance. One observer looking out for Liberal policy says the best guide is Gina Reinhardt’s Twitter (X) feed, but I have not researched the veracity of this.

Here is the article from Zali Steggall:

Budget
With $17 billion in tax cuts, this budget will benefit working Australians, but the government has again avoided meaningful tax reform. Of note, there is a downgrade to revenue from weak Petroleum Resource Rent Tax (PRRT) with forecast revenue slashed from $10 billion to $6.3 billion by 2026-27. Australia is collecting more tax from beer drinkers than fossil fuel companies. The government has again failed to scale back support through the diesel fuel tax credits for mining companies, now predicted to increase to $46 billion.

The extension of the energy bill relief ($150) is welcome but not means tested so includes an element of spending waste. Continued investment in community batteries and social housing electrification are steps in the right direction. However, there remains an urgent need for the government to prioritise renewable household energy through rooftop solar and battery programs which offer lasting cost-of-living reductions and emissions cuts.

The budget includes a number of positive measures in health and education, particularly for women’s health and affordable childcare, and continues some investment in future-facing industries like green metals.

One of the most promising developments in the budget is the government’s adoption of the Productivity Commission’s recommendation to eliminate non-compete clauses for low and mid-income workers—a measure that while not a headline grabber, will provide a much need boost to productivity and labour mobility.

It was also good to see a modest increase in foreign aid, in line with calls for Australia to strengthen its leadership in the region.

However, this budget fails to respond adequately to the climate and nature crises. Alarmingly, fossil fuels continue to receive six times the funding allocated to nature. There is no meaningful investment in environmental protection, or additional funding for an EPA despite the enormous and growing fiscal impact of natural disasters.

It’s a false premise to think we can prioritise a cost-of-living budget over climate measures as climate change is already costing us, and the longer we wait to mitigate and adapt, the more expensive it will be.

It is disappointing that the government announced a mere $28.8m over two years to ‘improve Australians resilience to natural hazards and preparedness to response to disasters’ in the same section it notes that Cyclone Alfred is estimated to cost $13.5b in disaster support and recovery. Piecemeal upgrades to roads in marginal electorates do not constitute a genuine resilience strategy.

Defence spending is accelerating, but national security isn’t just about weapons and wars – it’s about regional stability. Defence spending alone isn’t enough. When disasters strike, fragile infrastructure turns climate shocks into prolonged crises, fuelling unrest and displacement. True security means helping our neighbours build resilience before disaster strikes.

JobSeeker and Youth Allowance remain unchanged, so our most vulnerable are falling further below the poverty line. There is also a glaring gap in support for women and children escaping domestic violence, with only a $2.5 million increase for crisis accommodation—far below what is needed to address the scale of the crisis.

Climate and Environment
• No significant funding uplift for climate resilience and adaptation.
• Over $46 billion on fuel tax credits. This is six times more than funding for environmental protection.
• Downgrade in revenue forecast of the government’s weak petroleum resource rent tax.
Commentary:
• The government has acknowledged that climate change is expected to have a significant impact on the Budget, both in terms of risks and opportunities. However, there has been no new funding for climate adaptation and resilience, simply $28 million of targeted funding, including $17.7 million for the Bushfire Community Recovery and Resilience Program.
• The aftermath of ex-Tropical Cyclone Alfred has been felt throughout this Budget. With $1.2 billion allocated for disaster relief, the full cost is anticipated to rise to $13.5 billion.
• In terms of funding for disaster resilience, there has been little foresight to keep our communities safe with only $200 million expected to be provided over the forward estimates from the Disaster Ready Fund. Disappointingly, we also see a decrease of funding to the National Emergency Management Agency to assist with planning and preparing of future disasters from $27 million in 2025-26 to $12 million in 2028-29.
• We are still waiting for the government’s National Climate Risk Assessment and National Adaptation Plan to understand the full extent of climate risk for our communities. Unfortunately, the extent of new climate resilience investment is limited to flood proofing three roads with $354 million over the forward estimates.
• Despite the Government committing to better monitoring and reporting of methane emissions, there was nothing in the budget. It is disappointing that this funding was not prioritised given how critical it is that our emissions inventory has integrity to achieve the government’s 43% emissions reduction target and commitments under the Paris Agreement.
• In terms of nature, I welcome the government’s announcement of $250 million to fund Australia’s obligation to protect 30% of Australia’s bushland by 2030, but this is a far cry from the $5 billion estimated by the conservation sector. In addition to this, there is great hypocrisy in the $2 million in additional funding for protection of the Maugean Skate captive breeding program, when the government today rammed through legislation that puts the endangered species at risk.
Financial Relief for Individuals and Small Business
Progress
• Reforming Help to Buy Program to increase income threshold and house price limit
• Tax cuts for all Australians.
• $150 energy bill relief for every household and some small businesses.
• HELP changes come into effect – a 20% debt reduction, fairer indexation, and raising the minimum repayment threshold to an annual income of $67,000.
Falls Short
• Commonwealth Rent Assistance indexed but not increased.
• No ongoing funding for instant asset write-off, and no meaningful support for small businesses.
Commentary:
• It’s great to finally see the reforming of the Help to Buy scheme to start to match house prices in Warringah. Warringah has around 1% vacancy rate for rental properties and the average dwelling is more than $1 million. First home buyers are struggling to get their foot in the housing market, and this will help – but more needs to be done to reduce the cost of buying a home. However, there is still nothing to assist or support renters.
• I welcome the government’s investment into household electrification, including the continued funding of the Community Solar Banks Program and the Household Energy Upgrades Fund for supporting public and community social housing with electrification. This not only drives down emissions but also helps to bring energy bills down.
• For small business, there is limited financial relief in this Budget. The end of 2024 saw the highest number of insolvencies for small business over the past four years – our small businesses are struggling. We need to legislate a permanent instant asset write off for at least $50,000. It is vital that the Government legislates and makes this available to small businesses without delay.
• With cost-of-living pressures, it is concerning that there is no substantive uplift in Jobseeker, Youth Allowance, Austudy and Commonwealth Rent Assistance. I continue to advocate for the government to increase income support payments, such as JobSeeker, Youth Allowance and Parenting Payment, to at least $82 a day.
Economy and Industry
Progress
• $1 billion over 7 years for the Green Iron Investment Fund.
• $750 million for green metals.
• $2 billion for the Clean Energy Finance Corporation.
• $20 million to support trade diversification with India.
• $54 million to increase supply and adoption of pre-fabrication and modular homes to help increase Australia’s housing supply.
Falls Short
• Budget deficit.
• No new funding for circular economy initiatives.
Commentary:
• There’s been talk on both sides of the growing deficit however, there is limited announcements on how we are going to grow the economy through increased productivity. The Government’s already announced $900 million National Productivity Fund provides an avenue to grow a skilled workforce and push out productivity measures, including the $54 million for prefabricated and modular homes and to prohibit non-compete clauses for low- and mid- income earners. However, meaningful, long-term policies and spending are still needed to continue to grow our productivity.
• There is some movement by the Government to decarbonise key industries, with $250 million for manufacturing low carbon fuels for sustainable aviation and diesel-reliant sectors, including transport, agriculture and construction. I also welcome the New Energy Apprenticeships Program and national electrician licensing program to support Australia’s energy transition.
• The $20 million for a Buy Australian campaign, which appears to be the only measure the Government has included to address growing tariff and trade war tensions, feels a bit misplaced. In the face of increased uncertainty, the government has foregone any new funding to push for greater research and innovation programs.
Defence and National Security
Progress
• Funding for building Australia’s domestic defence industry and capabilities.
• Additional $135 million in funding for foreign aid.
Falls Short
• No new funding for the Defence Net Zero and Defence Future Energy Strategies.
Commentary:
• Increased global tensions has meant that Australia’s previous heavy reliance on the US as our security backstop can’t be relied on anymore. As a result, there has been additional $1 billion dollars provided to defence in the Budget. This has been bundled with the $9.6 billion in defence funding that was already planned to be spent over the next four years.
• It’s going to be vital to have clear KPIs and deliverables from such an increase in defence spending to ensure that Australia gets value for money and necessary capabilities.
• I welcome the $5.1 billion allocated in Australia’s aid program. This announcement is a timely and much needed signal of our regional commitment and reversing the long-term decline in funding.

Safety at Home, Work and Online
Progress
• $6 million for ACCC’s National Anti-Scam Centre.
• $21.4 million for the implementation of the Australian Law Reform Commission inquiry into the justice responses to sexual violence in Australia.
• $175 million for NDIS integrity and cracking down on fraud.

Falls Short
• No funding for gambling advertising reform.
• No commitment to implementing an online duty of care or holding big tech to account.
• No new funding for Indigenous legal services, despite calls from the National Aboriginal and Torres Strait Islander Legal Services for $1.15 billion.

Commentary:
• Aside from the funding to the ACCC’s National Anti-Scam Centre, there has been limited funding to online safety with no new funding for the e-Safety Commissioner’s work on keep young people safe online.
• Australia continues to face a crisis of women’s safety, yet while the investment of $21.8 million over 2 years for First Nations early intervention and prevention, only a mere $2.5 million has been allocated to crisis accommodation for women and children, which will make little to no difference at a national scale.
• It’s a strong start to see the allocation of $21.4 million in funding to over 3 years to implement the recommendations of the Australian Law Reform Commission’s Inquiry into the Justice System’s Response to sexual violence.

Education
Progress
• Full funding to government schools.
• $1 billion to establish the Building Early Education Fund to increase the supply of high-quality early childhood education.
• Three Day childcare Guarantee funded with $426.6 million.

Falls Short
• No measures to implement real time processing of HECS debt repayment to address indexation timing inequity of HECS.

Commentary:
• An additional $407.5 million will see that government schools receive full funding under the School Resource Standard.
• Investment into the early childhood education fund, paired with the 3-day childcare guarantee, is an important and necessary measure to support young families and assist young parents in returning to the workforce.
• A modest investment of $4.8 million is welcome to ensure the continuation of education programs to encourage update of STEM.
• The current Fee-Free TAFE agreement between the Commonwealth and state governments expires in 2027. I welcome the commitment to continue funding the Fee-Free TAFE program, as VAT.

Health and Wellbeing
Progress
• $7.9 billion for Medicare to increase bulk billing services and incentivise GPs to bulk bill patients.
• $793 million funding for women’s health initiatives, such as additional contraceptive pills on the PBS, menopausal hormone therapies added to PBS and 11 more endometriosis and pelvic pain clinics.
• $43.6 million over 4 years for treatment of neuroendocrine tumours.

Commentary:
• A number of promises have been made during the course of the election campaign that are now reflected in the budget but there are no significant new measures.
• I welcome the focus on women’s health with $793 million funding for initiatives, such as oral contraceptive pills on the PBS, and efforts to lift support and care provided by GP’s for women experiencing menopause.
• With just over 50% of all medical appointments bulk billed in Warringah, the cost of healthcare is a concern within our electorate. The government announced a lofty goal of 9 out of 10 doctor visits, however, I question whether this is realistic.
• Further, the capping of PBS prescription medication at $25 dollars is welcome, but more needs to be done to ensure that the cost of the PBS medicines doesn’t blow out the budget.
• An announcement of $291.6 million over 5 years to implement aged care reforms is welcome although will do little to address the significantly long wait times to access aged care services in the short term.
• Funding of $1.8 billion for public hospitals is welcome to assist state governments deal with strained emergency services in public hospitals.
• Efforts to address GP shortage with $663 million in funding to create more pathways for GPs and nurses. This is necessary measure in making healthcare more accessible.
• The investment into medical research and particularly rare cancers is important in promoting the health of everyone in our community. This includes $158.6 million over 5 years for the Zero Childhood Cancer Precision Oncology Medicine Program and the Australian Rare Cancers Portal.
• There are also some minor investments in sport that promote inclusion. I welcome the $3.2 million for the Australian Sports Commission to support women’s participation in sport.

Conclusion
On balance, I give this budget a C+ as it represent cautious fiscal management in challenging geopolitical and economic circumstances but it lacks the ambition and reform required to address climate risks, close equity gaps and secure a strong, fir economy for future generations.
Disappointingly, we see noi new funding for the Australian Electoral Reform to assist with tackling disinformation during the election campaign.
There are no new measures positioned to strengthen the existing National Anti-Corruption Commission.

27/01/2025

NDIS and Health System in Crisis- what is the answer?

27 January 2025

The health system has been in crisis for years and now NDIS is the same.
State and Federal governments are locked in crisis talks, and now the NDIS is over budget and looking to ‘transfer services’ to other parts of the health system.
Why does all this go on, and what is the solution?
The short answer is that there are many sources of health funding and the main policy objective of all of them is to transfer the cost to someone else, and if they are a private source, to maximise the profit.
This ‘transfer costs’ imperative means that no one is concerned about the overall cost, merely their bit of it.
The major players are still the State and Federal government. In simple terms the States look after the hospitals and the Federal government looks after non-hospital services.
Medicare is being starved and pays less and less to doctors relative to inflation. The private health funds pay what they have to, the CTP (Motor Accidents) and Workers comp systems are either private or use a private model and pay as little as they can get away with and the patient pays the gap, unless they decide that private health insurance is not worth the money, which in most cases is true, and get a bit of Medicare and pay the rest.

Examples of cost shifting are easy to find. The Federal government has let Medicare rebates to GP fall to 46% of the AMA fee. It was 85% when Medicare started, so many doctors simply don’t bulk bill and charge a fee. So people go to the Emergency Departments that are free, but funded by the States. A visit to the ED is 6x more expensive than a GP visit, but the Federal government has shifted the cost to the States, so they don’t care. When you go to the ED and get a script, the hospital used to give you all the drug course. Now they give you a few tablets and a script for a pharmacy outside. The script was needless, and generates the costs of the trip to the pharmacy, the pharmacists fee, the PBS Federal government contribution and the patients script fee. A lot of wasted time and money, but the State saved a bit. When you went to the ED, you used to be followed up in a hospital outpatient clinic where the consultant was paid a sessional fee and oversaw registrars checking the cases and learning. You could also just book and go to a specialist clinic. These have largely been stopped to save the State money. Now you go to the specialists’ rooms and the State saves money, but the total cost per visit is much more.

If you look at the overall efficiency of health systems, Medicare as a universal system has overheads of about 5% counting the cost of collecting tax generally. Private health insurance overheads in Australia are about 12%, Workers comp 30% and CTP over 40%. These figures are approximate and very hard to get, because the dogma is that competition drives down prices, when clearly the system is more efficient if there is a single paying entity. Interestingly, the Productivity Commission made no attempt to quantify these overheads when it looked at the cost of the health system- you may ask why. The point is if you take out profits, which are the same as overheads from the patients’ point of view, and make everyone eligible, you do not have to have armies of insurance doctors, investigators, lawyers and tribunals to see if the insurer has to pay or if it can be dumped on Medicare and the patient.
As far as foreign people using the system are concerned, universal Medicare for people living in Australia is administratively simple, and the cost of treating tourists who have accidents is cheaper than policing the whole system. Enforcement has quite high costs.

In terms of the cost of insurance, US schemes vary from 12-35%R, with the high costs ones being most profitable as they police payouts more thoroughly and naturally refuse more treatments. Note that the CEO of Unitedhealthcare in the US was recently shot, with the words ‘deny’ and ‘delay’ on the cartridges used. Surveys have shown that 36% of people in the US have had a claim denied. Claims are accepted here, but in a survey of my patients 60% of my scans and referrals of CTP patients were denied by NRMA. i.e, We accept the claim, but deny the treatment.

What Is needed is a universal system, free at the point of delivery.
What about over-servicing? The current system makes trivial problems of people with money more important than major problems of people without money. Underservicing is the major problem with ambulance ramping at EDs and long waiting lists.
In a universal system, which doctor is doing what is immediately accessible, with comparisons to every other doctor doing similar work. It is just a matter of checking up on the statistical outliers.

The problem is simple. The major political parties are given donations by private health interests to let Medicare die. Combine this with the Federal/State rivalry that makes cooperation very difficult and a reluctance to collect tax and you have the recipe for an ongoing mess.

The NDIS is an even bigger mess. It is a privatised unsupervised welfare system that arbitrarily gives out money and is subject to massive rorting.

The welfare system that looked after people with disabilities, both congenital and acquired by age or circumstance had grown up historically in institutions that were fossilised in their activities and underfunded to prevent expansion or innovation. People with disabled children looked after them with whatever support they could find. As these disabled cohorts reached middle age, their parents, who were old, were worried about what would happen when they died and wanted to lock in funding for their adult children before they died. They were an articulate lobby group with real problems and were quick to point out the flaws in the existing systems. They visited institutions that had no vacancies and thought that they had put their names on waiting lists. But no central list existed, and the institutions tended to give their beds to whoever came first when a death created a vacancy. ‘Just give us a package, and we will decide how to spend it’ was the parents’ cry. But then NDIS experts came in and interviewed people and gave away ‘packages’ based on an interview. A new layer of experts was created. District nurses or others who might have been able to think of more innovative or flexible options, or who could judge who in their area needed more than someone else had no input. People with real disabilities were given money, but did not know how to assess providers, so dodgy operators snapped up the packages, delivering dubious benefits. The government had no serious regulation or control system. Now the cost of NDIS has blown out, so the solution is to narrow eligibility and force people off the NDIS and onto other parts of the health system. Sound familiar? People with disabilities and their relatives are naturally worried; and rightly so. The lack of these services was why the NDIS was created. The answer is to have universal services. Set a standard, make it available and police quality in the system. Private interests may have a place, but there is no need for profits, non-profit organisations have been the mainstay of providers for years. For profit providers tend to cut costs, which in practical terms means either services or wages or both to concentrate on shareholder returns. The best way to allocate resources optimally is to empower the people actually doing the job, who also have the advantage of being able to see relative needs as they go about their routine work.

An interesting tome on the subject is ‘The Political Economy of Health Care’ by Julian Tudor-Hart, which looked at the changes in the British National Health System from when it started as an idealist post-war initiative run by those working in it with management overheads of about 0.5%, to when it was fully bureaucratised with overheads of about 36%. He was also responsible for the ‘’Inverse care law’ which is the principle that the availability of good medical or social care tends to vary inversely with the need of the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.

The key point of that people have been taught that governments are hopeless and that you should pay as little tax as possible, so instead of good universal services being developed, a market has developed which is on its way to an American system.. People all agree that the US has the worst system in the developed world at delivering health care. But they overlook the fact that the US health system is the world’s best at turning sickness into money. That is what it was designed to do and that is why it is sustained and maintained. The same drivers are all here.

Note the Federal/State bickering in the article below (and weep).

My recipe for change is to have a Swiss style of government where the people can initiate binding referenda on governments and could simply answer a question like ‘Do you want to pay 5% more tax to have a universal health and welfare system?’ If a question like this got up against the doomsayers, we might have a chance. But of course the change to the constitution to get the referenda in the Swiss model is almost impossible to achieve, the Swiss having been discarded when the Australian Constitution was written in about 1900.

www.thesaturdaypaper.com.au/news/politics/2025/01/25/exclusive-albanese-shut-down-hospital-talks-pressure-states?utm_campaign=SharedArticle&utm_source=share&utm_medium=link&utm_term=VT5jI6Zo&token=Z3cA3Py

08/12/2024

Health Insurance Executive Targeted in New York

6 December 2024

A top health insurance executive was killed in what seems to be a targeted shooting in New York’. It seems that he was threatened over ‘health insurance issues’.
Every day I see patients who have their perfectly reasonable treatment requests refused by workers comp or CTP (Compulsory Third Party = Green Slip) insurers. The ‘case managers’ who are grandly titled case clerks have little power and follow protocols dictated by more senior folk in the organisati0on. I am unsure if they get bonuses for cases costing less than some statistical average for that type of claim, but nothing would surprise me. Sometimes it seems that they just refuse treatments because they think that they will get away with it, but the odds are stacked that they will often succeed anyway. The case clerks (Case ‘Managers’) cop a lot of abuse and are rotated frequently, perhaps to prevent their abuse or perhaps to prevent them getting to know their ‘clients’, who some of us would call ‘patients’. The case clerks have very little discretion and the system is very slow and seems designed to ensure that absolutely no one could ever be overpaid. The clerks follow their protocols, and are often unavailable and do not return calls. Most use their first names and a letter (presumably the first letter of their surnames) presumably so that they will not be personally targeted by those whose treatments they are refusing. (One would have thought that as people handing out money to people in distress that they might be very popular). It is as if one side are playing a game with money, but for the other side it is deadly serious.
Given that about a third of the population live from paycheck to paycheck, the fact that insurers have 3 weeks to accept or reject the whole claim, then 3 weeks to approve or deny any treatment, and longer if it is a difficult case, a huge amount of human misery can be created without even stressing any protocols. Governments are keen to keep premiums low and seem keen to support any insurer –suggested legislative amendments that achieves this aim. Interestingly the NSW Parliamentary Committee reviewing the NSW Workers Compensation legislation in 2022 had no input for either patients or doctors or their organisations. Presumably they did not seek such input and there was no publicity for the inquiry.
I see in my practice many distressed people whose lives are destroyed by these treatment denials. Now with the insurers only liable for the first 5 years after injury, if they can delay treatment longer than that, they are off the financial hook and the patients need to be treated by Medicare if that is possible. When I say ‘if that is possible’, many specialists will not do any Medicare work as it pays less than half the private rate. The waiting list is usually over a year for non-emergencies and the specialists are even more reluctant to treat cases that should have been paid by workers comp or CTP insurers. Even that assumes that the patients have Medicare; overseas students or people on working visas do not.
My belief is that insurers want to control medicine and the WC and CTP insurers, now with considerable input from the American Health insurance industry are preparing for the (very soon) day when Medicare is irrelevant and insurers tell doctors what they may do.

The patients whose lives are destroyed by the insurer denials of their reasonable treatments are upset and angry, often shattered physically and by the loss of their homes, properties and marriages do not think through how this has all happened. They are angry with the ‘case manager’ but not those higher up in the organisation who set the protocol that was the basis of their treatment denial.
Years ago, when I went to tobacco control conferences in the USA, there would sometimes be discussions among doctors about how to treat various medical conditions. Amongst the non-Americans, the talk was about what regimes were best. The Americans were usually concerned with what the insurers would pay for to the point that it was sometimes frustrating to have them in the conversations. I won a Fellowship in 1985 to study workplace absence and got some flavour of the way treatments were denied. I now see it all unrolling in Australia.
In the US guns are easy to get. When I saw a US health executive had been shot by an unknown person, I did not find it hard to find a motive, and thought that there could probably be a very large number of suspects. I Australia the case managers do not dare give their surnames, but the top executives are still all on the company websites.
If we continue to let Medicare be defunded because of private health donations to the major political parties and put money ahead of people’s reasonable needs, we will follow the Americans.

Here is the Reuters article in the SMH 6 December 2024

Health executive shot dead on New York street

Brian Thompson, the chief executive of UnitedHealth’s insurance unit, was fatally shot yesterday outside a Midtown Manhattan hotel in what appeared to be a targeted attack by a gunman, New York City police ofﬁcials said.

The shooting occurred in the early morning outside the Hilton on Sixth Avenue, where the company’s annual investor conference was about to take place. Thompson was rushed to a nearby hospital where he was pronounced dead. The attacker remained at large, sparking a search that included police drones, helicopters and dogs.

“This does not appear to be a random act of violence,” New York City Police Commissioner Jessica Tisch said. “Every indication is that this was a premeditated, pre-planned, targeted attack.” The suspect, wearing a mask and carrying a backpack, ﬂed on foot before mounting an electric bike and riding into Central Park, police said. Law enforcement authorities said the gunman appeared to use a silencer on his weapon, CNN reported.

UnitedHealth Group said Thompson was a respected colleague and friend to all who worked with him. “We are working closely with the New York Police Department and ask for your patience and understanding during this difﬁcult time,” it said in a statement. “Our hearts go out to Brian’s family and all who were close to him.”

UnitedHealth Group is the largest US health insurer, providing beneﬁts to tens of millions of Americans who pay more for healthcare than in any other country.
Video footage showed the gunman arrived outside the Hilton about ﬁve minutes be
fore Thompson. He ignored several other people walking by, NYPD Chief of Detectives, Joseph Kenny told reporters.

When Thompson approached the hotel, the gunman shot him in the back with a pistol and then continued ﬁring, even after his gun appeared to jam. “Based on the evidence we have so far, it does appear that the victim was speciﬁcally targeted, but at this point, we do not know why,” Kenny said. The shooting happened not long before the scheduled investor conference at the Hilton.

UnitedHealth Group chief executive Andrew Witty took to the stage about an hour after the event started to announce the rest of the program would be cancelled.
“We’re dealing with a very serious medical situation with one of our team members, and as a result, I’m afraid we’re going to have to bring to a close the event today,” he said.

Police tape blocked off the area on 54th Street outside the Hilton, where blue plastic
gloves were strewn about, and plastic cups appeared to mark the location of bullet casings.
Thompson’s wife, Paulette Thompson, told NBC News that he told her “there were some people that had been threatening him”. She didn’t have details but suggested the threats may but suggested the threats may
have involved issues with insurance coverage. Eric Werner, the police chief in the Minneapolis suburb where Thompson lived, said his department had not received any reports of threats against the executive. The killing shook a part of New York that is normally quiet at that hour, about four blocks from where thousands of people were set to gather for the city’s Christmas tree lighting. Police promised extra security for the event.

“The police were here in seconds. It’s New York. It’s not normal here at seven in the morning, but it’s pretty scary,” said Christian Diaz, who said he heard the gunfire from the nearby University Club Hotel where he works.

Police issued a poster showing a surveillance image of the man pointing what appeared to be a gun and another image that appeared to show the same person riding on a bicycle. Minutes before the shooting he stopped at a nearby Starbucks, according to additional surveillance photos released by police. They offered a reward of up to $US10,000 ($15,500) for information leading to an arrest and conviction.

Governor Tim Walz of Minnesota, where the company is based, said the state was praying for Thompson’s family and the UnitedHealth team. “This is horrifying news and a terrible loss for the business and healthcare community in Minnesota,” he said in a statement. Thompson, a father of two sons, had been with UnitedHealth since 2004 and served as chief executive for more than three years. Thompson was appointed head of the company’s insurance group in April 2021 after working in several departments, according to the company’s website.

“Sometimes you meet a lot of fake people in these corporate environments. He certainly didn’t ever give me the impression of being one of them,” said Antonio Ciaccia, chief executive of healthcare research non-profit 46brooklyn, who knew Thompson. “He was a genuinely thoughtful and respectable guy.”
Reuters, AP

There was considerable follow up:

www.smh.com.au/world/north-america/bullets-used-in-us-healthcare-exec-s-killing-had-writing-on-them-20241206-p5kwa6.html

www.smh.com.au/world/north-america/wave-of-hate-flows-for-health-insurance-industry-after-ceo-s-shooting-death-20241206-p5kwcz.html

16/02/2024

‘Health Policy’

Chesterfield-Evans, A. (2024)

Journal of Australian Political Economy No. 92, pp. 98-105.

HEALTH POLICY
Arthur Chesterfield-Evans

Just before the 2022 federal election, Mark Butler, now the Minister for
Health in the Albanese government, spoke to the National Press Club,
praising the courage of the Hawke government in creating Medicare in
1984. His speech also set modest priorities for a prospective Labor
government, committing to (1) improve the digital health record and make
the MyHealth record actually useful; (2) develop multidisciplinary care;
(3) establish a new funding model for ‘MyMedicare’; and (4) grow the
medical workforce, with special mention of nurses and pharmacists (Butler
2022). Significantly, Butler did not commit afresh to Medicare as a
universal health scheme free at the point of delivery, the key element of
the original 1984 scheme that he praised. In an environment where,
politically, it seems that taxes cannot be increased, perhaps this ideal may
be an impossibility, but it is surely significant that it is no longer stated as
an aspiration.
Currently, Medicare is quietly dying as the low rebates cause doctors to
abandon it. Australia is moving to a US-type private system by
default. This has resulted in large amounts of hand-wringing rhetoric, but
so far little action. This short article comments on the changes initiated by
the current Labor government during its first year and a half, contrasting
these with the deep-seated problems needing to be addressed if better
health outcomes are to be achieved.
Labor’s reforms
The government has made some minor changes to Medicare which came
in with great fanfare on November 1, 2023. There were new item numbers

for new specialist technologies or treatments and an increased Medicare
rebate for GPs, up to $41.40 for a standard visit for a RACGP member,
which is 40.6% of the AMA fee. Doctors without the RACGP qualification
still get $21, which is 20.6% of the $102 AMA fee.
When Medicare was born, the Medicare rebate was 85% of the AMA fee.
The rebate has risen at half the inflation rate for 39 years, so doctors now
feel ripped off every time they see a Medicare patient. Labor blames the
disparity on the rebate freezes of the previous LNP Coalition governments,
but its own record is poor. Successive governments of all types have
deferred to the private health lobby and are starving Medicare, slowly
defaulting towards a principally private system, as in the USA. This is a
deeply-troubling prospect because the US health system has been
recurrently criticised (Commonwealth Fund 2021) – and rightly so –
because it makes access to health care dependent on ability to pay. Notably,
however, it is the world’s best system at turning sickness into money.
The other recent Labor ‘reform’ was to allow pharmacists to process
prescribed medications to cover patients’ requirements for 60 days, rather
than 30 days, thereby halving the costs of prescribing and dispensing.
While this may seem helpful, patients are often confused by complicated
generic names and generic brands; and compliance or discontinuation of
medicines is a largely unquantified problem. These are existing problems
with the current arrangements for dispensing medications: the recent
policy change, while well-intentioned, does not redress them. It transfers
resources from professional staff to the pharmaceutical industry.
The ‘Strengthening Medicare Taskforce’ had good medical and allied
health representatives and support. Its December 2022 report defined the
problems but, trying to avoid controversy, positive suggestions were thin
on the ground. A deeper analysis and more comprehensive approach to the
redress of health issues is needed.
Basic problems in the health system
Diverse funding sources causes cost-shifting
Fundamentally, no-one is in overall control of the health system. It has a
number of different funding sources: the Federal and State governments,
the Private Health Insurance industry (PHI), Medicare and individuals

themselves. Workers Compensation (WC) and Compulsory Third Party
(CTP) insurers also put in a bit. These arrangements lead to a situation
where each funding entity attempts to shift costs without any real care for
the overall cost of the system. Private entities such as pathology and
radiology also have an interest in providing more services, whether they
are needed or not.
The broad division of the health system is that public hospitals and
emergency departments (EDs) are State-funded, and non-hospital services
are Federally, PHI or self (patient) funded. There is some overlap,
however, because the State’s provision of some community-based services
allows them to save on hospital-bed days; and private funds paid to State
hospital in-patients are eagerly sought. The starvation of Medicare (which
reduces the Federal government’s spending) has resulted in more patients
going to EDs at higher (State) cost, as well as increasing PHI and patient
costs.
This cost-shifting has evident implications for the affordability of health
care: notably, a recent study showed that Australia, when compared to 10
other countries, scored poorly on its measure of affordability
(Commonwealth Fund 2021).

A new health paradigm is needed
Yet more fundamentally, there is a huge problem with the conceptual
model of the health system. In common parlance, the ‘health system’ is the
‘paying to treat illness’ system. Paying doctors to see and treat patients is
seen as the major cost and is the most politically fraught element in the
system.
Historically, everyone was assumed to be healthy and had episodes of
either infectious diseases or surgical problems. They went into a hospital
for a brief period and either recovered or died. The legacy of this is that
heroic interventions are over-resourced and the more cost-effective early
interventions are under-resourced.
Infectious disease is now relatively uncommon, notwithstanding the recent
and ongoing coronavirus concerns. Most disease is chronic; and the
objective is to maintain health for as long as possible and to support those
who need support in the community rather than in institutions. ‘Health’
must be re-defined as a state of physical and mental wellbeing; and
maintaining it as ‘demand management’ for the treatment system.

Life-style diseases of diet, obesity, smoking, vaping, alcohol, drug-use and
lack of exercise need attention. It might be commented that these habits
are more determined by the political economy of the products than by any
health considerations; and the government should intervene to re-balance
this market failure.

Hierarchies, cartels and corporatisation
The medical system is hierarchical with specialists at the top and GPs at
the bottom. The specialist colleges have produced less practitioners than
would have been optimal. The starvation of General Practice has led to
increasing specialist referrals for simple procedures. Most patients are
happy to go along with this, though often much less happy about the rising
costs. Practitioners tend to work down to their station rather than up to
their capacity. GPs, if given the appropriate additional education and
empowered to act, could do what quite a lot of specialists do now, while
nurses could take the load from GPs; and, in terms of home support, a more
comprehensive and flexible workforce needs to be developed.
Private medical insurance systems are a further source of problems. They
have marketing, churn, profits, liability and fraud issues; and they make it
necessary to account for every item of every procedure. While the
corporations watch every cost, the regulator cannot. Corporations buy
medical practices and take up to 55% of the gross revenue. Smaller
radiology practices are being gobbled up as investments (Cranston 2020).
If overheads are defined as the amount of money put in compared to the
amount paid for treatments, Medicare costs about 5% and PHIs, as they
are regulated in Australia, about 12%. In the USA, the private health funds
take up to 35%, and Australia’s CTP system got close to 50%. A universal
health insurance system could avoid many of these costs and would be far
superior from a social equity point of view.
Similar problems are evident in the provision of care for people with
disabilities. Labor pioneered the NDIS when last in office a decade ago,
and rightly claims this as evidence of its commitment to redress the
previous neglect. However, the NDIS can be considered as a privatisation
of the welfare system. It overlaps medical system functions and is poorly
regulated. If its efficiency is judged by the percentage of money put in that
is paid to the actual workers delivering the service, care is not very

efficient. There have also been significant criminal rip-offs (Galloway
2023).
Retirement care arrangements have major flaws too. Aged-care
accommodation is largely driven by the real estate industry; and access to
continuing care is an add-on of often dubious quality.

What should the government do?
The problems described above are diverse, deep-seated and not easily
rectified. However, a government intent on staying in office for a series of
terms could heed the call for some big thinking, drawing on the experience
of health practitioners themselves. Here is a list of what might be done,
becoming more medical and more politically difficult as it progresses:
• Keep people healthy with education, clean water, sanitation, housing,
good food, regular exercise, high vaccination rates, road safety,
universal swimming lessons, CPR and first aid training and the active
discouragement of smoking, vaping, alcohol and drug use, junk food
and gambling.
• Provide housing with graded community support options for those
people with disadvantage or impairment. Create a registration and
insurance system for home and community support services, so that
individuals can buy standardised services from other individuals.
• Maintain fixed staff-patient ratios related to the disability
classification of residents in institutional care.
• Make maximum use of community and school interventions and
support services such as District and Community nurses and School
nurses, mental health support networks, Aged Care Assessment
Teams, Hospitals in the Home etc.
• Address health problems as early and as low down the support and
treatment hierarchy as possible, by empowering those who provide
the services.
• Create a meaningful regulatory, inspection and enforcement system
for support services, both community and residential, and for
workplaces and recreational facilities.
• Use the medical information system to research drug and treatment
effectiveness.

• Support General Practitioners and try to increase their ability to solve
problems without referral. Have GPs work in Health Centres with
community support workers as far as possible; and improve
communication with data collection a by-product of normal work, not
an additional imposition.
• Have independent evaluation of the numbers needed in the specialties
and pressure the colleges to provide these numbers. Use waiting times
as an initial index.
• Initiate either university-based or college-based continuing medical or
professional education, with mandatory refresher exams every
decade.
• Have universal professional indemnity insurance, with doctors and
other health professionals unable to be sued if they report all incidents
of sub-optimal outcomes within 48 hours of becoming aware of them,
and participate in regular quality control meetings.
• Publicise and promote organ donation, end of life plans, wills and
enduring powers of attorney as sensible steps in life-management.
• Evaluate Intensive Care interventions in QALY (Quality-Adjusted
Life Years) terms, researching their outcomes and comparing them to
earlier intervention initiatives.
• Change the composition of the Pharmaceutical Benefits Advisory
Committee so that it has no pharmaceutical industry representative on
it; and remove ministerial discretion from its decisions. The previous
system evaluated new drug listing approvals with a cost-benefit
analysis (Doran et al. 2008), but the Howard reforms of 2007,
following the Australia-US Free Trade Agreement and lobbying by
Pfizer, put a drug industry representative on this committee, making
its negotiations more transparent and thus more difficult for the PBS
to negotiate prices (Access to Medicine Working Group 2007).
• Work towards replacing Workers Compensation and CTP insurance
schemes with income guarantee schemes (this will only be possible
when Medicare allows timely treatment).
• Create a credible and indexed scheme for paying medical
professionals which does not have KPIs that distort performance.

• Make Medicare a universal taxpayer funded health system that is free
at the point of delivery and stop subsidising PHI. It might be noted
that the Government currently quotes Medicare and PHI costs
together as a sum rather than itemising the two, which serves to
disguise the subsidy to PHI (Parliament of Australia 2022).

Conclusion
The current federal Labor government has made statements about health
policy reform and done minor tinkering during the first year and a half in
office. Based on this start, it is doubtful that it will have the courage to
make the necessary major changes, addressing the systemic problems.
Fine rhetoric is unlikely to achieve much. That makes it doubly important
to develop proposals for more fundamental reform. Written with this
intention, the suggestions made in this article could be the basis for
tackling the fundamental institutional and political economic issues
problems associated with personal and societal ill-health.
Dr Arthur Chesterfield-Evans trained as a surgeon in Sydney and the UK
and is a Fellow of the Royal College of Surgeons. He currently works as a
GP with interests in workers’ compensation and third-party injury. He has
been a tobacco activist and an elected member of the upper house of the
NSW Parliament. He has Master’s degrees in Occupational Health and in
Political Economy.
chesterfieldevans@gmail.com

References
Butler, M. (2022) ‘Address to National Press Club, 2 May,’ available:
www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-
care-speech-national-press-club-2-may-2023.
Commonwealth Fund (2021) US Report, available:
www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-
reflecting-poorly.
Cranston, M. (2020) ‘Radiology enjoys a post-virus buying boom’, Australian Financial
Review, available: www.afr.com/policy/economy/radiology-enjoys-a-post-virus-buying-
boom-20201106-p56c7k.

Doran, E., Henry, D., Faunce, T.A. and Searles, A. (2008) ‘Australian pharmaceuticals policy
and the idea of innovation’, Journal of Australian Political Economy, 62, pp. 39-60.
Galloway, A. (2023) ‘Federal crime syndicates using cash vouchers and gifts to steal NDIS
funds’, The Sydney Morning Herald, available: www.smh.com.au/politics/federal/criminal-
syndicates-using-cash-vouchers-and-gifts-to-steal-ndis-funds-20230414-p5d0ma.html.
Parliamentary Library (2022) Health overview, available:
www.aph.gov.au/About_Parliament/Parliamentary_departments/Parliamentary_Library/p
ubs/rp/BudgetReview202223/HealthOverview.
PBS (2007) ‘Access to medicines working group’, available: www.pbs.gov.au/info Access to
Medicines /general/working-groups/amwg/amwg-jul-2007.
Sax, S. (1984) A Strife of Interests: Politics and Policies in Australian Health Services,
Sydney: George Allen and Unwin.
Searles, A., Jefferys, S., Doran, E. and Henry D.A. (2007) ‘Reference pricing, generic drugs
and proposed changes to the Pharmaceutical Benefits Scheme’, Medical Journal of Australia,
187(4), pp. 236-39.
Strengthening Medicare Taskforce (2022) Taskforce Report, Commonwealth Department of
Health, available: www.health.gov.au/sites/default/files/2023-02/strengthening-medicare-taskforce-report_0.pdf.

07/12/2023

Hospital Crisis is just part of the story.

6 November 2023

The hospital crisis is partly because General Practice has been so downgraded that more cases go to hospital than need to. The Federal government starving Medicare has a number of consequences:
Many GPs are simply retiring and there are no enough new ones taking their place, so we are getting towards a serious shortage
GPs cannot survive on the Medicare rebate, so now charge a co-payment.
Since Emergency departments are free, people wait until the situation gets worse then go there.
Emergency Depts are about 6 times the cost of GP visits, so the total cost of the Health Care system rises.
The other part of the Federal government starving Medicare is that the State governments pay for the emergency departments, so it is a case of the Federal government saving money by making it a lot more difficult for the States.
But an overriding fact is that Australia has been convinced by the neo-liberals that tax is a bad thing and government spending must be a small percentage of GDP. Currently this is about 38.4% of GDP, slightly less than the USA, which has very poor welfare and health systems. This means that the governments cannot actually afford to do anything, and behave like a corporation, cutting employee wages and making cuts wherever it thinks no one will notice, or it has the power to do so. Now if Labor ever tries to raise taxes, the Liberals, who are great exponents of small government accuse Labor of being ‘tax and spend’, and Labor, rather than have a serious debate merely retreats. The fact that he Scandinavian countries have government as close to half of GDP and have their citizens much better off never gets mentioned. Denmark is at 49.9%, Germany 49%, Finland 54% and France at 54%. The UK is at 45%.
We now have a failing GP sector, a problem in aged care, a shortage of nurses, paramedics on strike, a hollowed out public service that merely awards its former tasks to private sector operators that it cannot even monitor and Australia falling down the World educational standards table is not a coincidence. The governments have a virtual monopoly of these jobs. They have deliberately let wages fall, so that now people simply will not do them.
We need to stop privatising, rebuild that public sector so that it can deliver services that we need. Profit is merely another unnecessary overhead. We need to decide what needs to be done, and raise enough tax to pay the people to stay in their public service jobs. Education, health and aged care do not need a ‘market’ to function/. If one exists for comparison purposes, that is fine, but there is no actual virtue in having most of the services delivered by corporations that have the choice of good service or good profits. It is a con, and it is time we forced the government to give us Medicare and a health system that actually works for all, and education for all.
Here is a letter from my Medical partner in today’s Sydney Morning Herald.

The horror stories now emerging about overloaded public hospitals, ambulances and emergency departments comes as no surprise to anyone following the downgrading of Medicare to a ‘‘mixed billing’’ system. This has made it unaffordable for many people to see a GP. But the real cost of turning Medicare into a two-tier system has been to the public hospital system. The only winners are private corporations, private hospitals, private health insurance funds and their many lobbyists in Canberra. We are going the way of the US, and if people don’t fight for Medicare, we are all doomed.
Con Costa, Hurlstone Park:

Here is today’s Herald Editorial

Health system needs its own emergency care
The state of health of the health system has dominated the lives of Australians for four years, but it has never been in such need of urgent care. Indicative of how working conditions for frontline healthcare workers have deteriorated, people now spend a median of three hours and 36 minutes in NSW hospital emergency departments, the longest wait ever. It’s little wonder that health workers are suffering burnout, stress and bullying and are leaving the industry in record numbers.
The COVID-19 pandemic sharpened awareness of our vulnerabilities and forced extra spending on hospitals, clinical responses, vaccinations and prevention measures.
And when we emerged from the pandemic’s worst days it became evident the health system too was experiencing difficulty recovering from years of stress. It had been deteriorating for a long time already, but post-pandemic we became uncomfortably aware that ambulances were queueing for hours to offload emergency patients and hospitals were under enormous pressure with lengthy wait times in emergency and admission.
GPs bumped up fees, forcing people who could not afford the $11-a-visit hike into hospital emergency departments. The industry is being further destabilised by the exodus of 6500 nurses and midwives a year.
If anything, the situation is worse outside the big cities. Last year, for instance, five deaths in regional hospitals could potentially have been prevented, but not in an overworked hospital system with staff shortages that make mistakes even more likely. The NSW parliament’s health portfolio committee report on rural, regional and remote health 18 months ago found a ‘‘culture of fear’’ which did not encourage or value feedback and complaints. Some workers say they were even punished for making complaints.
Now an investigation by the Herald has revealed a health system sinking further into crisis. Eight nurses and midwives have taken their lives in the past three years, while nearly 2000 NSW Health workers have lodged compensation claims for psychological injuries over the past two years. More than 33,500 NSW Health employees have also claimed they are burnt out, while 21,000 workers say they have witnessed bullying in the workplace. One in 12 ambulance employees hold a compensation claim for a psychological injury.
Experts and unions warn that the data, drawn from documents obtained exclusively under freedom of information laws and the state government’s recently released annual employee survey, People Matter, shows a workplace struggling with staff mental health concerns.
Further illustrating the stress, NSW Ambulance fielded a record 363,251 calls and fired up the lights and sirens for more than 181,000 emergency call-outs between July and September, the most of any three-month period since the Bureau of Health Information began taking records in 2010.
Money seems to be the root cause of health’s problems. Today’s national cabinet meeting will address the rampant cost blowouts in the NDIS and Canberra wants the states to take responsibility for funding treatments. On Friday, Premier Chris Minns and Treasurer Daniel Mookhey meet the Health Services Union over a protracted pay dispute threatening to collapse the NSW triple zero call system on New Year’s Eve. Minns said the money is not available.
The future funding and structure of our health systems concerns us all. It is an area where the federal and state governments share responsibility. The solution to the healthcare crisis is complex and will take time, but it is an area where increased funding must be found.
That clearly calls for a better national approach and the states responding with an end to parochial wheelbarrowpushing and finger-pointing.

24/11/2022

iCare- a letter to the Editor of the Sydney Morning Herald

24 November 2022

Dear Editor,
iCare was set up by private insurers on their model with the NSW government keen to minimise costs, take profits and distribute them (just before the last election). So iCare delays or refuses treatments to the needy, and was very careless about what their Pre-Accident Average Weekly Earnings (PIAWE) were. Many accident victims complained that they were underpaid, and that was before their compensation was stopped or cut because they were certified partially fit to do jobs that could not be found.

The overheads of Medicare are about 5%, iCare about 38%, so it is totally inefficient as well as incompetent with bloated salaries for the top executives who think it is a financial problem rather than a medical one and hence are unable to solve it. The real solution would be to fund Medicare as the only medical system and let the insurers have widespread income-guarantee insurance.
Sincerely
Dr Chesterfield-Evans- works as a GP specialising in Workers Comp and CTP injuries.

Here is an article from today’s SMH

EXCLUSIVE
Injured workers to lose benefits
Adele Ferguson

Greg Dayman is one of almost 400 workers who will get a Christmas ‘‘present’’ they will never forget.

The Sydney construction worker was badly injured on a building site in 2013, which left him unable to work with chronic pain in his neck, the side of his head, down his arm, torso and leg.

In 2017 he was among thousands of employees whose compensation payments to cover wages were cut as part of controversial reforms to the state’s scandal-ridden icare organisation. Changes to the legislation terminated injured workers receiving weekly wage benefits after five years unless they met a whole body impairment assessment of more than 20 per cent.
However, he still received medical or health benefits. Now he has found out even these will be cut from December 25.

‘‘It’s another upper-cut,’’ he said. ‘‘And to do it on Christmas Day, that’s just cruel.’’

Dayman is one of 395 workers facing a grim future as a crisis at icare deepens, with a document prepared by the State Insurance Regulatory Authority (SIRA) revealing the workers’ compensation scheme ‘‘has deteriorated to the point the longer-term sustainability of the scheme is under threat’’.

NSW Auditor-General Margaret Crawford will hold a performance audit into icare next year that will examine how effectively key risks are managed, including the rising cost of workers’ compensation claims and its payment processes. Dayman said he lost everything after his injury.

‘‘I lost my health, my career, and financially I’m in a position that if my specs break I can’t afford to buy them. The system dehumanises you, so you give up.’’

He does now qualify for a disability pension but will have to rely on Medicare for future medical treatment. ‘‘I have been suicidal at times because of the system and the way it treats you,’’ he said. ‘‘My time is spent trying to survive.’’

In the executive summary of SIRA’s review into icare’s Nominal Insurer Improvement Plan, dated September 26, the authority said it had a ‘‘low level’’ of confidence icare’s strategy would improve return to work rates and overall performance.

In 2015-16, 93 per cent of injured workers were back at work 26 weeks after their injury, compared with 84 per cent in August 2022.
SIRA said it believed icare’s strategy ‘‘encompasses an increase in work capacity decisions to cease worker benefits instead of focusing on improving health and recovery through return to work’’.
Richard Harding, icare’s managing director and CEO, said it was the insurer’s role to implement the law, and legislation ‘‘does not give icare any discretion to act outside that’’. ‘‘Tailored and individualised support is provided to workers transitioning from the workers’ compensation scheme,’’ he said. ‘‘This may include support from NDIS, Community Support Services and Medicare in conjunction with their GP.’’

This masthead this week revealed a third underpayment scandal of injured workers and concerns raised by NSW Treasury in August that a deterioration in icare’s finances would require insurance premiums to rise 33 per cent by 2025, or $1 billion a year, to cover the shortfall.

Against this backdrop, the icare board granted pay increases to 116 of its executives, including Harding, making him one of the state’s top-paid public servants, earning more than $1 million a year.
Shadow Treasurer Daniel Mookhey said icare’s finances were in a catastrophic condition.

‘‘They’ve lost billions. They are planning massive premium hikes. And their next step is to expel even more injured workers from the system,’’ he said.

‘‘It is a ruthless tactic stemming from their financial desperation.’’
In a statement, SIRA chief executive Adam Dent said its views on the Nominal Insurer Improvement Plan in September were made with limited detail on how the plan would be executed.

‘‘Over recent weeks, SIRA has continued to engage with icare to address information gaps, including detailed briefings on managing IT and transition risks associated with the onboarding of new claims services providers.’’

But SIRA said poor return to work performance continued to be an issue of concern.

‘‘Icare’s targets for 2023 are lower than current return to work rates, and they are projecting a further decline of 2.5 per cent on 26-week return to work rates through 2023 and 2024 as the scheme transitions to new claims providers,’’ Dent said.

Icare said its focus was building injured workers’ capacity for employment using rehabilitation providers and associated vocational placement interventions. ‘‘This includes assistance with job seeking and vocational retraining. Work capacity decision-making is applied when the worker has a demonstrated capacity for work and has been provided the right support.’’
Lifeline: 13 11 14

12/05/2022

What is Needed in Health

12 May 2022

Dr Stephen Duckett was an architect of Medicare and is one of our leading health policy experts. His opinion of what is needed for the health system has a lot of implied criticism of what has been happening, with excessive resources on late-stage treatments rather than prevention and early diagnosis, which comes in Primary Care.He speaks of the dis-cordination, cost shifting and political nature of decision-making.

He does not even mention the need to fix Medicare- saving it is not enough!

What I would do if I were the Minister for Health and Ageing in the next government

24/02/2022

Loneliness and its solutions

25 February 2022

I sometimes watch Foreign Correspondent on ABC TV and by chance on 15/2/21 I came across this excellent programme on loneliness in Japan.

The ABC correspondent there looks at loneliness in the Japanese population from older folk dying alone, to younger people simply withdrawing from society.

Some of the older ones had no family or jobs. Some of the younger ones were so pressured to succeed and felt that they had failed, so simply withdrew from society. It seems that the pressure on kids all to be CEOs is an absurd and unachievable objective.

I am not sure that the situation in Australia is as bad, but I thought about some of my patients and could think of half a dozen immediately. With some of them , I am one of the only two or three people in the world they have any contact with, their relationships are tenuous.

None of them started with mental health problems. Here are some examples:

A 60 year old man worked for a security company looking after an insurance company. He was doing surveillance for them, but it took over his life as he was contacted 24 hours a day for various crises. Case management employees having conscience over what they were doing had to be rescued from self-harm in the toilets. Enraged claimants with refused claims threatened to blow up the company offices with cans of petrol. He saw staff high-fiveing as some claimant got a derisory settlement when they deserved and needed a lot more. It went on like this for years. When he said that he could not do this anymore he was treated as badly as any of the people he had dealt with. He told me this story, and I had hoped that with his considerable management skills and experience, he could be put into a less stressful position. But he deteriorated. Everything reminds him of the corruption of the world. He is estranged from his wife and they communicate with post-it notes on the frig. He goes for a walk at 11 at night so he will not have to speak to people in the street. One son has stuck by him and visits daily, and will build him a self-contained unit in his new home.

Another patient is a 62 year old ethnic taxi driver who was so badly bashed 11 years ago by a gang stealing his takings that he lost an eye, has never worked again and never recovered mentally or physically. He was divorced; lives alone and sometimes will not even answer the phone.

One is a 42 year old foreign student who came to study theology, wanting to become a pastor. Her English is not great. She is a trifle unworldly, and thought that the world is basically kind and people look after each other. She had a casual job in a motel and her boss asked her to move a bed down the stairs between floors. She said it was too heavy and she could not, but he threatened to sack her. She did it and got an injury to two discs in her back. She was frightened to have surgery, so was in agony for a couple of years and eventually agreed. She had minimal surgery, which was not successful. The insurer decided that she was not complying with what they wanted so refused to pay her. She was effectively broke and homeless, so an old lady from her church offered her a bed and food. But she lives a long way away and up a drive that is hard for my patient to walk up. She was effectively trapped. As a foreign person she did not even have Medicare for the minimal psychological help it offers (6 visits a year). Her mental health deteriorated and she shunned all outside contact, and would not even answer the phone. She has gone home to her family- I can only hope she improves there.

One is a 39 year old from a religious and teetotal family with a high sense of ethics. He was a top salesman of a computer company and became aware that they were ripping off some customers. He drew this to management’s attention, but they declined to do anything and he was labelled a whistleblower. Management supported him by putting out an email asking that he be supported for his mental health issues. He felt that this ostracisation was the end of his career, because he had asked them to behave ethically. He was certain that no one in his tight top group will now employ him, so he withdrew and started to drink to lessen the pain. His family then rejected him because of the drinking and his sales friends are estranged also. The psychologist gives him Cognitive Behavioural Therapy exercises and I try to get him to drink less and somewhat ironically counsel him that you cannot withdraw from the world merely because the baddies generally win. He lives alone, answers the phone and is just able to do his own shopping, but is not improving much.

These are just some examples that I know. Coasting home as GP at least keeps you in contact with life. The point is that many people have broken lives, but just keep living. None of these examples have done anything wrong themselves. Is a sense of ethics a mental illness?

As everyone has to ‘look after themselves’ in a consumer-oriented society, more people will fall through the cracks, especially as the gap between rich and poor is enlarged by pork barrelling which puts resources into areas that need them less, tax breaks for the rich, subsidies for private schools and private health insurance, derisory welfare payments, and insurers allowed simply to refuse to pay without penalty.

People need basic support with universal housing and universal health case. They need jobs or at least occupations and an adequate income to survive. And we need outreach and support services that can be called upon.
When people say, ‘There are not enough jobs’, they are taking nonsense. Anyone can think of many worthwhile things that need doing. And there are plenty of people who would be happy to do them. The problem is that in a world where nothing can be done that does not make a profit, a lot of things that need doing are not done. That is where the policy change are needed. We cannot simply look at the money and see to what level existing activities can be maintained. We need to look at what needs to be done, and then work out how to achieve it. We need to decide that everyone has a right to live and those who have a good life will live in a better society if everyone can share at least a basic quality of life. There has to be recognition that the ability to be profitable need not be the overwhelming criterion for what is done. Tax may go up, but if there is real re-think of priorities, it is not likely to be all that much.

The link to the ABC program that initiated this tirade is below.
https://iview.abc.net.au/show/foreign-correspondent/series/2022/video/NC2210H002S00

05/01/2022

COVID Day 4- a non-PCR Day

5 January 2022

I did nothing today- it just took longer than usual.

I felt much the same, a sore throat, not much energy, a bit of a headache and bouts of a dry cough. I did not feel like exercise and I thought that I had better try to get a PCR test and some Rapid Antigen tests in case we needed to prove we were not infectious, or had other people who were concerned contacts.

I researched online where the PCR (Polymerase Chain Reaction) tests were being done. The site I used 2 weeks ago, a 4Cyte drive through test that had taken an hour to do and 3 days and 16 hours to get results from was closed Wed-Friday. It was not clear why this was but the Laverty Pathology group at 60 Waterloo Rd near Macquarie Centre was open till 4pm. I took a novel in case of a long wait and drove there.

As I approached from the google direction cars in the left lane were not moving from the major intersection as far as one could see to the next hill. Many of them had their tail lights on, so I reflected that they were sitting in a line with the engines on. Bad for the environment, but it at least told me that his was the queue. I turned off the engine and started to read. After a while I was wondering why no progress at all was being made, and I thought I might ask if I was under some misapprehension. As I looked up, a pleasant looking woman in her mid-30s got out of the small car ahead, and went to her boot.

I called to her out the window, ‘Is this the PCR test queue?

‘Reckon so’, she said, ‘I’ve brought some snacks to get through it’. She took some biscuits, grapes and a drink and got back in.

We advanced glacially slowly, and I noticed that there was a side road a little way down the queue. Space had been left so cars could go in and out of this side road, but cars had also started to queue there, and of course the two queues merged at the intersection. I had not thought of this until I was nearly at the corner, and I suppose the woman in the car hadn’t either. Some on the side road were shouting abuse or tooting as if we were somehow pushing in to their queue. There were no signs, no guides and nothing online, so it seemed that the only fair thing to do was to take alternate cars. My young friend had recognised this before I had and moved her car across the middle of the side road, so that cars exiting or entering could go in front or behind her, but she could be sure that the side road queued cards did not just push in. There was a cacophony of abuse from the side street.

The queue moved forward a few cars, so I followed her closely, letting one car in as seemed fair. A large 4WD with a man screaming obscenities at me tried to push in, but I kept him out. I wondered if he would get out and make trouble but he did not. The passenger in the car I had let ahead of me had got out and was remonstrating with the woman who had been in front of me. It was tense. I was very glad we were not in America with some people having guns.

We continued our glacial advance, then a car coming in the other direction stopped. The driver stuck his head our and was shouting something to those in the queue ahead of me. I could not hear him, but he did not seem abusive, so as he passed I called to him to ask what he had said. He said, ‘They have closed early; I was second in the queue and they told me to go away’. It seemed likely that he was right, but most people had waited so long that they were not willing to drive off, so we moved quite slowly till everyone had driven past the ‘Closed’ sign that had appeared in the driveway. It was 2pm. The testing site was advertised to be open till 4.

No test and a couple of hours wasted. I have COVID. It is not recorded in the system. It seems that I will recover. Will I waste another few hours tomorrow? And if I do will I have PCR results anyway? I am scheduled to see my patients again 9 days after the onset of symptoms- presumably I will be non-infectious. Luckily I got some RAT kits.

It is not hard to see where anger and frustration comes in all of this.

‘Personal responsibility’ has a very Darwinian edge.

Thank God I am not very sick.

22/09/2021

Victorian Government Bites the Bullet and Mandates Vaccination

22 September 2021

At last! A government that does the sensible thing. The Victorian government will only open up if people are vaccinated. Thanks to NSW the Delta variant genie is out of the bottle and spreading nationwide. Business wants to unlock, some with no care for anyone but themselves.

Victoria wants to unlock but minimise spread among those now having more interpersonal contacts. The R (Reproduction) number is the number of cases each case infects. If everyone is vaccinated, less people will get it and those who have it will get it to less people.

Reasonable medical opinion is that the risks of vaccine are massively less than the risks of getting COVID, so the case against vaccination is incredibly weak on medical grounds. The ‘right not to have your body violated’ etc sounds very dramatic, and makes vaccination equivalent to rape in a semantic sense. But in a practical sense the two concepts are as far apart as could be. One is sensible medicine and the other is a crime.

Anyone who thinks that this does not matter should look at the graph of NSW cases that has peaked and is just starting to fall. Anything that can flatten the curve or make it fall is good. Anything that makes it rise is creating deaths and misery.

I am a member of the Council for Civil Liberties and have spent years working against excess government power. But sometimes it is necessary to act for the common good. I have no time for smokers’ rights or the right to spread disease. The Morrison government is as usual missing in action when real leadership is needed. ‘Let every workplace decide’, is a nightmare for retail business owners, offices and just about every other employer. Gladys is similarly missing. Dan Andrews has stepped up, despite a motley crew in the streets spreading disease and demanding the right to continue to do so.

What of the Health System? We are going the way of the Americans by stealth, and the fact that the public system is what has helped us survive is being glossed over, hidden by subsidies to private hospitals. The Federal government has been quietly trying to kill public medicine for years. The Medicare rebate has fallen from 85% of the AMA rate to 45%, so for the same bulk-billing work doctors incomes have almost halved over 35 years, while subsidies to the inefficient Private Health Insurers continue. Being a GP is now a little-sought speciality. (I have a FB page- Fix Medicare that I spend too little time on).

The States have maintained the public hospitals at a minimal level, as all the lucrative work has been siphoned off by the private system basically doing the easy stuff. There is No slack in the system, not that counting the number of ICU beds should factor. All our efforts should be to keep people out of Hospital and ICU by prevention of infection.

Have a look at this article on the anti-discrimination aspects of mandatory vaccination, and also look at the NSW cases, just turning down, but likely to rise if anything, like opening up from lockdown, tips the balance.

www.smh.com.au/national/victoria/here-s-why-no-jab-no-entry-is-not-discrimination-20210920-p58t2v.html?fbclid=IwAR2jrbfGJsq6fD-J-unnAn12j9UyWvdk-do5BpE23bI0z0gQ8kknq5nc39c