Doctor and activist
08/09/2021
8 September 2021
John Quiggin gives a good, insightful summary in The Monthly.
www.themonthly.com.au/issue/2021/september/1630418400/john-quiggin/dismembering-government?utm_medium=email&utm_campaign=The Monthly Today – Wednesday 8 September 2021&utm_content=The Monthly Today – Wednesday 8 September 2021+CID_77319af0620e0ea97965a0e5af6e7e60&utm_source=EDM&utm_term=The Monthly#mtr
10/07/2021
10 July 2021
The current issue in the NDIS (National Disability Insurance Scheme) is the government’s efforts to introduce ‘independent assessments’ of people on the scheme and those who want to get on the scheme. The idea has been abandoned for the present, but that is not the end of the story. It is the beginning.
Some context is needed here. I was on a State Parliamentary inquiry into disability funding during which we heard evidence of inefficiencies within the disability sector where often there were shortages of appropriate services, and in some areas there were none at all. The real crunch time was when parents with children with disabilities realised that they were going to die eventually and wanted to make a plan for the rest of their child’s life. People would apply at various facilities, and be turned away as there were no places. They then assumed that they were on a waiting list, but usually no lists were kept. When a vacancy occurred, whoever applied at that time got it. It was mainly luck. Naturally the people trying to help their loved one wanted a guaranteed package that would continue after their death. More articulate parents and carers, who had struggled for years just wanted the money to buy the services that they felt that they needed. Many carers simply wanted more services, and hoped that a national system that guaranteed services for disability.
Given the political context of privatisation and reducing government involvement in everything, the scene was set to have disability services delivered by the private sector as a massive market for services. The private sector naturally wanted to get access to services that had been provided by government as a source of business and profit.
Government also had a real estate agenda. Some large institutions were on valuable land. The large facilities at Peat Island in the Hawkesbury and Stockton Disability Centre was on beachfront land just north of Newcastle. There was a residence for the grossly disabled opposite Wollongong Hospital that had taken years of fundraising for the parents to achieve. These could be sold off as the mental health facilities had been a few decades earlier, with the catchy slogan of putting the residents ‘back in the community’. The idea that the residents were better off isolated in a suburban homes with few facilities rather than in a community of people with the same problem and a well-structured programme of activities seemed a dubious proposition to me. Resident groups such as the relatives of long-term psychiatric facilities at Bloomfield in Orange were very scared of the suggested changes. There had been problems with the old system and some inappropriate facilities, but an overall lack of facilities was the major problem. It was not even throwing the baby out with the bathwater; it seemed more like smoke and mirrors.
The key question in dealing with any problem is how big a task is it? When the Committee asked how many people with disabilities there were, there was no answer. No register was kept. The two ways of calculating it were:
The latter method gave figures about ten times greater. So clearly if help or services were made more available, the numbers involved were going to blow out hugely from what was currently funded.
John Howard passed the Aged Care Act in 1998, which was the blueprint for the privatisation of the sector. Old people are very vulnerable. They have often sold the family home, so they are temporarily cashed up, looking for accommodation and long term care with mental and physical facilities failing, or they would not be there. Carers faced with responsibilities that they were not used to and uncertain of what care was needed were easy pickings also. The whole sector is more like a dysfunctional real estate market; a market failure due to insufficient ‘consumer information’, but also distorted incentives and priorities.
The NDIS was similar. Private operators with slick marketing made promises which would not be tested for some time, but people were signed up now. The not-for profit sector had never paid staff well, but most had a ‘care ethos’. Some of the private providers did not, and regulatory supervision was minimal. The government was pro-business and trying to give away responsibility.
But an absolute shortage of services was still a big factor. A neighbour who was a 95 year old retired academic widower wanted 2 hours a week of home help. For some reason he could not get a community nurse. The best deal he could get was 2 sessions of 2 hours at $65 an hour. The lady delivering the service was paid $21/hr. So much for private services; the ‘overheads’ are huge. I had suggested to Kevin Rudd’s 2020 Vision in 2000 that the Government needed to licence service providers as individuals if they wanted a market model, and our neighbour could have selected a person on a one to one basis. (I never even got an acknowledgement).
Now the government wants ‘independent assessors’ to evaluate cases, presumably to lessen costs. A number of points can be made about this. It assumes that the assessors will learn more about the patient in an interview than the people who work with them already know. The new management philosophy since the 1980s always assumes that a manager at the top will know more than the person actually doing the job. Naturally if the object is to save money and have the person at the bottom paid minimally, requiring no skills and interchangeable in staffing, this may be true. But if the people at the bottom were respected, trained and empowered, the need for the middle level experts might be much less.
‘Independent Medical expert’ assessors are used in the Workers Compensation and CTP systems. They work for agencies hired by insurance companies. Often they find the patients either have nothing wrong with them, or it is degenerative and not related to their injury. These experts are even flown from interstate and save insurers money by denying treatments. Presumably if they find in favour of the patients, their agency gives them less work. The agency takes its cut and has to please the insurer. So the systems are more complicated and an ever higher percentage of the money is spent in trying not to give services. The NZ National Accident Compensation scheme, though it was government owned, went to a private insurance model and the same thing happened. Doctors who had a track record of denying liability were flown around the country to do their medicals.
The assumption may still be that well intentioned assessors still can do better. My widowed mother lived alone in the family home and had a stroke. A neighbour noticed her confused, walking on the balcony. She recovered, but seemed to have lost some judgement. She was assessed by an ACAT (Aged Care Assessment Team) who said that she could live alone in supported accommodation. So we got her into a unit in the grounds of an old house, where she could book a dinner at a days’ notice in the communal dining room, have a nurse onsite during the day, and had a right to a nursing home bed if she ever needed one. Seemed perfect. She said that she could look after herself. Can you microwave a dinner? Yes. OK. Do it. It got done. No problem. Dinners in the frig. Sweets in the jar on the mantelpiece; see you in 2 days. Arrive in 2 days. Dinners still in the frig. Lolly jar empty. Very hungry- can we go to lunch? She could do anything when asked, but could not initiate a process. She could not think to get a dinner from the frig, or book lunch tomorrow in the communal dining room, nor ask for help. The one-off team could not pick this. Neither did the family. But it emerged when the situation at home was known. This is just a story, but a carer who is savvy and properly trained will know more than a university-qualified assessor who has only a short knowledge of the patient. And naturally the person on the job actually delivers the service and is not an extra cost. They can also judge relative needs of people on a run or in an area if resources are limited.
So the scheme to bring in assessors is the tip of an iceberg.
Private insurance models have huge problems at many levels. The overheads of Medicare are a bit under 5%. The overheads of Private Health Insurers are about 12%, and they cannot refuse to pay doctors. The overheads of US Health insurers are about 12-36%, as the best way to improve profits is to cut costs (payments to patients) rather than increase services and then try to prove you have and sell on that basis. At the bottom of the efficiency barrel is our own NSW CTP system with overheads of almost 50%. The question has to be what is the focus of the system? Delivering services, or saving money? The US health insurers, like our CTP scheme are very good at making money. What they make their money from just happens to be people rather than widgets. The main cost savings of privatisation seems to be destroying award conditions and lowering ‘staff costs’. The immense administrative savings from universal systems, where determining entitlement and paying for profits are eliminated cannot be matched by any private system, despite what the ideologues might pretend.
The NDIS is currently a fund supposedly to help people with disabilities. These people apply to get ‘packages’ of money and services. Businesses persuade people to spend their packages with them. It is a market. But there are more people with disabilities than was expected, for the reasons discussed above. So a new level of assessors, were to be rolled in, but a huge outcry has prevented this temporarily. But the problems that led to the need for the assessors remain implicit in the design of the NDIS, which is fatally flawed. The government, particularly this one, is not going to take this very large bag of lollies from the private sector. The totally inefficient Private Health Insurers (PHI) give money to political parties and advance by stealth, letting Medicare become irrelevant for health care. Disability is now also privatised, and a new private lobby is in there. It has not yet generated a Royal Commission into its rip-offs, but it will, not that the Aged Care Royal Commission has stopped the privatisation of aged care. The political forces are too great. It is ironic that as Medicare is starved and pays less and less of the doctors’ fees its levy was increased, using a wave of sympathy for people with disabilities to make a bigger pool of money for increasingly private disability providers.
How to fix the problem?
I do not pretend to have all wisdom on this, but in dealing with difficult political problems I think it is wise to set a direction, take some basic steps and consult widely, looking for advice particularly from those who do not get an immediate financial benefit.
Here is a start:
Recognise that disability is not a sickness. Some disabilities are inherited; others are acquired due to accident, illness or aging. The sector is quite diverse, often divided up by the type of disability or how it was acquired. Sickness has an ‘episode’ model, based on traditional infectious diseases or surgical treatment models. Disability tends to be long-term and may improve or be worked around, or may degenerate gradually. As such it needs long-term solutions like welfare, but using the term ‘welfare’ now implies charity. Disability funding is funding to enable those less fortunate to have as normal a life as possible. From our common wealth, we give more to those who need more so that our society has equal opportunity for all. We are being taught that tax must be minimised and if we are getting less than we pay we are being ripped off. A better model is to consider the statement by Rhonda Galbally, ex-CEO of VicHealth, ‘There are two populations, the disabled and the not-yet disabled; if you are lucky enough to be in the second group, you should be happy to help pay for the first’.
The idea of a universal service obligation is the cornerstone. We should start with the assumption that people with disabilities should live in our society with as normal a life as possible and we should adapt to support them in as cost-effective way as possible.
My suggestion is that the Community Nursing service is the basic structural framework. We assume that people with disabilities will be living in society, and need varied and integrated support. If they are born with a disability or acquire one, they will come in contact with the acute hospital system, which will hopefully document their situation and alert the community support system. People on the ground will then liaise with family to see what support there is for independent living, and organise resources, calling in specialists of required. The cost of home support may be part of a package or allowance. Individuals may register to offer services for everything from shopping, cleaning and lawn mowing to medical or paraplegic support services. The government will register and insure both practitioners and those who use their services and may put training requirements on those who wish to register for some skills. A market with consumer feedback as exists for restaurants or other practitioners will allow people to hire help directly without big corporations adding massive overheads.
Whether the monies are paid separately of via Centrelink is an administrative question, but Centrelink has to have a major makeover so that it is not the niggardly decider of the ‘worthy poor’ with its chief function being to avoid paying anyone, or paying as little as possible. If society cannot find everyone employment, we must share what we have to those who are disadvantaged by disability or circumstance. This will collide head on with the problem of increased numbers of those with disabilities, but the extra load must be seen as part of having a decent society.
The way we are going seems to be privatising, allowing huge profits, then running out of money and shutting the gate on those who do not yet have packages. The independent assessors were merely the instruments of Managers who were not able to make their own assessments and did not trust the people who actually deliver the services. The assessor problem was the tip of the iceberg of a system that has all its underlying assumptions wrong, but sadly has a lot of political power that having been created, may not be able to be undone. The first step is to understand what is happening. Hence this lengthy post.
www.abc.net.au/news/2021-07-09/ndis-disability-independent-assessments-model-dead-after-meeting/100277324
28/05/2021
28 May 2021
This is a huge corporate scam. Why do people think that only little people are rip-off scammers? Also the idea that most people claims are ‘accepted’ is a nonsense. Insurers accept the claim, which means that they pay for a few GP visits and some physio. But they refuse to pay for scans that might find diagnoses. Then they refuse to pay for referrals to specialists who might need to operate. Then they refuse to pay for recommended operations. Then they use tame doctors (IMEs = Independent Medical Examiners) who either say that the condition does not need the treatment or that the problem was there before the accident so the insurer is not liable.
So the government introduced the PIC (Personal Injury Commission) to arbitrate all the claims that the insurers had refused. Now the waiting time for the PIC is over a year, which suits the insurers fine as the doctors and patients will use Medicare or private heath insurance to get the treatments and the insurers will either pay less or not have to pay at all.
If you thought the banks were bad, you have not dealt with insurers. NRMA refuses a considerably higher percentage of treatments than anyone else in my statistics, and SIRA declines to keep statistics on the ‘industry’ as a whole, and no insurer has ever been prosecuted for refusing a treatment.
This is why we need Medicare- a single, just, efficient, universal health insurance scheme.
www.youtube.com/watch?v=Sp8R856f7cM
15/11/2020
I attended a DRS (Doctors Reform Society) zoom webinar on the future of health care with Professor Stephen Duckett and aged care with Professor Joseph Ibrahim of Monash Uni, a geriatrician whose experience is in evidence-based aged care.
It was not encouraging.
Preamble:
My own experience of nursing homes was initially as an after-hours doctor when I used to judge nursing homes by what I turned the Urine Smell Index; the worst ones smelled of urine when you opened the door at night. As a GP years ago I found it increasingly difficult to find someone trained to talk to about the patients’ treatments.
In New South Wales Parliament as an MP I was asked to pass legislation that lessened the number of trained nurses required on staff. ‘Flexibility’ was the key and many homes and facilities ‘had people who were not really sick’ we were told. I was not convinced but the legislation went through anyway.
When my widowed mother was no longer able to cope at home and the family went looking for supported accommodation it soon became clear that the driving force in Aged Care is real estate profits. The family home is sold and the object is to get the family to buy an overpriced retirement Villa with varying levels of support in the villa and then hopefully automatic entry into an attached nursing home, usually with quite a poor urine smell index. When the old person dies the villa profit largely reverts to the corporation.
A dear old widower professor who lived up the road needed support in his 90s. The home support contract offered needed at least 4 hours per week at $65 per hour. The person delivering the care was paid $20 an hour. I am unsure how District Nurses are allocated.
In 2000 Prime Minister Rudd asked for ideas for his ‘2020 Vision’. I wrote and suggested that he register the skills and training of Home Care workers so that they could be hired and evaluated like Uber of any other online service and the ‘quality control and insurance’ would not be why the contracting agency became so ‘vital and expensive’ (that it would end up costing more than the person who actually did the work). I never even had an acknowledgement of my suggestion.
Prof Duckett was of the opinion that things had got a lot worse since the 1997 Aged Care Act, John Howard’s work, which created ‘a business opportunity’ Prior to this there was a system called CAMSAM which was two modules; Care Aggregated Module and Standard Aggregated Module. These were funded separately. If they did not spend their Care money it was forfeited, so they could only profit on Services.
After 1997 there was no distinction so profits could be made from either component, so the quality of care declined, usually with lower staffing levels.
Some private-for-profit nursing homes have good care, but this is not common. Some not-for-profits also had very poor care, but the general rule is that the standard of care relates to the number and training of staff. The low wages (approximately equals $20 per hour) mean that the staff need to work multiple jobs in multiple locations which is what spread the COVID epidemic in Melbourne. Government run homes tended to have better staffing ratios, so were better able to act against the infection.
Professor Joseph Ibrahim commented that the terms of reference of the current Royal Commission on Aged Care were very narrow, only covering 5 years, and could not lead to prosecution. He felt that this was deliberate. The issues of overprescribing and assault have come up often.
He felt that this meant that it’s conclusions might be weaker and then not implemented, with a tendency to kick difficult problems down the road.
The commissioners themselves were of interest:
Richard Tracey had died before the enquiry started
Another, a Western Australian prosecutor had opted out (an unusual action as being on a Royal Commission is normally a good career move).
The two final commissioners are:
Commissioner, Briggs has put out a report asking that aged care be returned to the control of the health department. Prof Ibrahim comments that is very unusual for one Commissioner to make a public statement before the final report and this indicates that the commissioners are not in agreement.
Currently there are about 250,000 care workers and about 200,000 Professionals. The care workers need six weeks training at a TAFE level to get a ‘Certificate 3’ About 1/3 are new migrants. They are paid about $20 per hour and casualised to decrease staff costs. The unions are worried that the new RECP (Regional Comprehensive Economic Partnership) trade treaty actually allows trade in people and that more visas for cheap labour in these areas will not help residents or local jobs.
The $20 billion dollar industry is founded approximately $14.5 billion from government, $4 billion from RADS and $2-4 billion for additional services.
There are not-for-profits, but the large for-profit providers have increased since the 1977 act and are largely highly profitable big corporations, some multinational like BUPA.
Professor Ibrahim is concerned that there is a lack of supervision.
There are no forensic accountants looking at what it costs to run an aged care facility and this has allowed supernormal profits by big players. Money has been spent poorly or ‘hived off’. Obviously if the government runs some homes themselves there will be public service experience.
Prof Ibrahim believes that the future directions of aged care will be set by the multinational for-profit providers because these are the people who have direct access to the government. There is no significant advocacy for aged care residents. He contrasts this with breast cancer advocates who pressed for less radical operations, and for Gay men who pressed for more enlightened AIDS/HIV policies.
There have been discussions of ‘quality-of-life’ that have tended to be spoken of as needing less healthcare, but quality of life cannot be good without good health care.
The aged care industry likes home care as it lessens their costs and also pushes the liability back onto GPs. A sense of proportion is necessary:
There are 2.5 million well older people and 200,000 in aged care.
More radical treatments are now done in older age groups such as dialysis or cardiac surgery in the over 90s, very is some debate over this period some would say that it is a just to deny routine treatments but there is some distortion of priorities by having these lucrative procedures as fee-for-service, and there is also some inequity.
Since the development of antibiotics, medicines are seen as curative, but in fact they should be seen as being in three classes:
1. Curative
2. Palliative
3. Preventative
There is quite a lot of cost-ineffective medication use, such as for osteoporosis.
Solutions. (These are not just from the presenters)
Final Comment
Note there are a large number of public submissions on the Royal Commission website, many of which make discouraging reading. The privatisation seems to have led to profit-seeking rather than an improvement in care, and the political forces seem likely to continue this.
10/05/2020
10 May 2020 As Australian political parties slowly and steadily dismantle Medicare to move us towards a privatised system American-style, it is worth noting the major feature of the American system. Everyone says it is a hopeless system. It depends what you want it to do. It is the world’s best system at turning sickness […]
30/04/2020
30 April 2020The US health system which is largely private is poorly set up to handle a pandemic. It is set up to make money, so is not flexible when different equipment and procedures are needed. Added to this 12% of people have no health care insurance, so cannot get healthcare and of those insured, […]
21/06/2016
21 June 2016 This is a current question with Shorten claiming that the Liberals are trying to privatise it and Turnbull calling this a Labor lie. What is the truth? The answer is in the history of Medicare funding. Medibank was set up by the Whitlam government and the bulk billing frees were set at […]
21/06/2016
This is a current question with Shorten claiming that the Liberals are trying to privatise it and Turnbull calling this a Labor lie. What is the truth?
The answer is in the history of Medicare funding. Medibank was set up by the Whitlam government and the bulk billing frees were set at 85% of the AMA ‘Most Common Fee’. The 15% was a discount but saved doctors a lot of costs and all their bad debts. They got slightly less, but the clerical and hassles saved by simply sending the paperwork, and later the computer message to the Medicare computer was felt to be a good deal. But ever since then both major parties have not raised the Medicare same rate as inflation, in fact at about half the inflation rate. This has resulted in the Medicare rebate being about half the AMA fees. Specialists often will not see patients on Medicare unless they have a Health Care card, and GP practices simply cannot survive if all their patients are bulk billed. GP practices have survived by having pathology companies rent a room where they collect bloods for a relatively high price. This has allowed the government to keep the GP Medicate rebates low. Recently the government tried to change the pathology rebates, and the companies resisted, but the treat was that the pathology companies would stop subsidising GP rental and a whole fuss would have erupted re the uneconomic nature of General Practice. The government did not want this just before an election, so the pathology system was left as is. But can we trust the Turnbull government? I don’t think so. A couple of other pointers:
The Emergency Departments (EDs) have recently been in the news as having a hugely increased workload and there was a request for funds, also recently seen as a question to Turnbull on Q&A. EDs get busier if people do not go to GPs, who are far cheaper, and generally pick up problems earlier than EDs. So the rise in ED use is likely to be a reflection of the lack of funding of GPs by Medicare.
There have been a lot of rather convoluted plans to deal with chronic illness. As the population ages, and as it gets problems with obesity and diabetes, there are more visits, more prevention is needed. GPs are the cheapest medical intervention, so one might have expected that they would be the key element in the strategy to deal with it, perhaps supplemented by practice nurses or other slightly cheaper options based around GP-type community health centres. But instead of this there was a bemoaning of the difficulties and lot of convoluted nonsense trying to avoid raising GP payments to a viable level. It looked very like the object was not to find a solution to the problem, so that Private Heath insurers and the profit sector could get a look in at the problem and start to make some money.
Now we hear that there has been $5 million to look at outsourcing, just the payments part of Medicare. Well Medicare is Just a payments system, so that is the guts of it.
So it is very likely that the Libs want to privatise Medicare and take us to a US model of the health care. The public do not want this, but big business does, a powerful lobby in Canberra does, party political donors do, and the government can lessen the amount it pays for health, even though the total cost will rise dramatically.
Labor also has historically a very bad record. They have allowed the Medicare rebate to fall with inflation, had a rebate ‘freeze’ of their own, and their only promise is to stop the freeze, which still leaves most doctors either unwilling in the case of specialists or unable in the case of GPs, to survive.