more_vertDigital health has been defined as the “convergence of the digital and genomic revolutions with health, health care, living, and society”.1 The term is often used interchangeably with mHealth or mobile health because of the central role played by mobile devices. Remote patient monitoring and telemedicine constitute a subset of digital health technologies that enable monitoring of patients outside conventional clinical settings, such as in the comfort of their own homes. Evidence regarding the efficacy, effectiveness, economics, and clinical preferences of remote patient monitoring and telemedicine is growing in many chronic diseases, including heart failure, diabetes, chronic obstructive pulmonary disease, and stroke diagnosis, and in post-surgical care, rehabilitation, and behavioural medicine.
Preference: Economics
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[Perspectives] Reinhard Busse: leader in Germany’s health-system development
As head of the Department for Health Care Management at the Technical University of Berlin, Germany, Reinhard Busse enjoys a varied, interdisciplinary academic life. “I run a department of around 20 researchers, crossing disciplines including medicine, public health, business engineering, political science, and economics, a vast array of talent that is needed in the projects we run in the field of health systems performance”, he says. Busse’s analysis of Germany’s health-system characteristics and performance is detailed in the first paper of the Lancet Germany country Series.
Political message in National Press Club speech
AMA President Dr Michael Gannon has called on all sides of politics to take some of the politicking out of health, for the good of the nation.
Addressing the National Press Club of Australia, Dr Gannon said some health issues needed bipartisan support and all politicians should acknowledge that.
“Some of the structural pillars of our health system – public hospitals, private health, the balance between the two systems, primary care, the need to invest in health prevention – Let’s make these bipartisan,” he said.
“Let’s take the point scoring out of them. Both sides should publicly commit to supporting and funding these foundations. The public – our patients – expect no less.”
During the nationally televised address, broadcast live as he delivered it on August 23, Dr Gannon warned political leaders that the next election was anyone’s to win and so they should pay close attention to health policy.
“Last year we had a very close election, and health policy was a major factor in the closeness of the result,” he said.
“The Coalition very nearly ended up in Opposition because of its poor health policies. Labor ran a very effective Mediscare campaign.
“As I have noted, the Government appears to have learnt its lesson on health, and is now more engaged and consultative – with the AMA and other health groups.
“The next election is due in two years. There could possibly be one earlier. A lot earlier.
“As we head to the next election, I ask that we try to take some of the ideology and hard-nosed politicking out of health.”
In a wide-ranging speech, the AMA President outlined the organisation’s priorities, while also explaining the ground it has covered in helping to deliver good outcomes for both patients and doctors.
The AMA’s priorities extend to Indigenous health, medical training and workforce, the Pharmaceutical Benefits Scheme, and the many public health issues facing the Australian community – most notably tobacco, immunisation, obesity, and alcohol abuse.
“I have called for the establishment of a no-fault compensation scheme for the very small number of individuals injured by vaccines,” Dr Gannon said.
“I have called on the other States and Territories to mirror the Western Australian law, which exempts treating doctors from mandatory reporting and stops them getting help.
“We also need to deal with ongoing problems in aged care, palliative care, mental health, euthanasia, and the scope of practice of other health professions.
“In the past 12 months, the AMA has released statements on infant nutrition, female genital mutilation, and addiction.
“In coming months, we will have more to say on cost of living, homelessness, elder abuse, and road safety, to name but a few.
“Then there are the prominent highly political and social issues that have a health dimension, and require an AMA position and AMA comment.
“All these things have health impacts. As the peak health and medical advocacy group in the country, the community expects us to have a view and to make public comment. And we do.
“Not everybody agrees with us. But our positions are based on evidence, in medical science, and our unique knowledge and experience of medicine and human health.
“Health policy is ever-evolving. Health reform never sleeps.”
The address covered, among other things, health economics: “Health should never be considered just an expensive line item in a budget – it is an investment in the welfare, wellbeing, and productivity of the Australian people.”
Public hospital funding: “The idea that a financial disincentive, applied against the hospital, will somehow ‘encourage’ doctors to take better care of patients than they already do is ludicrous.”
Private health: “If we do not get reforms to private health insurance right – and soon – we may see essential parts of health care disappear from the private sector.
The medical workforce: “We do not need more medical school places. The focus needs to be further downstream.
“Unfortunately, we are seeing universities continuing to ignore community need and lobbying for new medical schools or extra places.
“This is a totally arrogant and irresponsible approach, fuelled by a desire for the prestige of a medical school and their bottom line.
“Macquarie University is just the latest case in point.”
And general practice: “General practice is under pressure, yet it continues to deliver great outcomes for patients.
“GPs are delivering high quality care, and remain the most cost effective part of our health system. But they still work long and hard, often under enormous pressure.
“The decision to progressively lift the Medicare freeze on GP services is a step in the right direction.”
On even more controversial topics, Dr Gannon stressed that the AMA is completely independent of governments.
While sometimes it gets accused of being too conservative, he said, it was not surprising to see the reaction to the AMA’s position on some issues – like marriage equality.
“Our Position Statement outlines the health implications of excluding LGBTIQ individuals from the institution of marriage,” he said.
“Things like bullying, harassment, victimisation, depression, fear, exclusion, and discrimination, all impact on physical and mental health.
“I received correspondence from AMA members and the general public. The overwhelming majority applauded the AMA position.
“Those who opposed the AMA stance said that we were being too progressive, and wading into areas of social policy.
“The AMA will from time to time weigh in on social issues. We should call out discrimination and inequity in all forms, especially when their consequences affect people’s health and wellbeing.”
Last year, the AMA released an updated Position Statement on Euthanasia and Physician Assisted Suicide.
It came at a time when a number of States, most notably South Australia and Victoria, were considering voluntary euthanasia legislation.
There was an expectation in some quarters that the AMA would come out with a radical new direction. But it didn’t.
“The AMA maintains its position that doctors should not be involved in interventions that have as their primary intention the ending of a person’s life,” Dr Gannon said.
“This does not include the discontinuation of treatments that are of no medical benefit to a dying patient. This is not euthanasia.
“Doctors have an ethical duty to care for dying patients so that they can die in comfort and with dignity.”
The AMA also takes Indigenous health very seriously.
Dr Gannon travelled to Darwin last year to launch the AMA’s annual Indigenous Health Report Card, which focused on Rheumatic Heart Disease.
“In simple terms, RHD is a bacterial infection from the throat or the skin that damages heart valves and ultimately causes heart failure,” he said.
“It is a disease that has virtually been expunged from the non-Indigenous community. It is a disease of poverty.
“RHD is perhaps the classic example of a Social Determinant of Health. It proves why investment in clean water, adequate housing, and sanitation is just as important as echocardiography and open heart surgery.
“The significance of challenging social issues like Indigenous health, marriage equality, and euthanasia is that they highlight the unique position and strengths of the AMA.
“The AMA was recently ranked the most ethical organisation in the country in the Ethics Index produced by the Governance Institute of Australia.
“People want and expect us to have a view – an opinion. Sometimes a second opinion.”
Chris Johnson
A transcript of the full address can be found here:
media/dr-gannon-national-press-club-address-0
Increasing funding to improve outcomes for eating disorders
The Federal Budget allocated $80 million for Australians with a mental illness such as severe depression, eating disorders, schizophrenia and post-natal depression resulting in a psychosocial disability, including those who had been at risk of losing their services during the transition to the NDIS.
The Government also announced it will provide $9.1 million over four years to improve access to psychological services through telehealth in regional, rural and remote Australia.
Health Minister Greg Hunt has also freshly announced that eating disorders will be included in the 5th Mental Health Plan and that the current Medicare Benefits Schedule Review Taskforce investigate Medicare coverage for the treatment of those with an eating disorder.
The National Mental Health Commission described the funding announcement as timely.
“Timely that eating disorders will be recognised officially as serious and complex mental illnesses with serious physical consequences,” said the Commission’s chief executive Peggy Brown.
The Butterfly Foundation, which is the country’s peak support organisation for people with conditions such as anorexia and bulimia, says that the current health system is failing people with an eating disorder.
Its chief executive, David Murray, said: “Too many times in the past 12 months Butterfly staff have sat vigil with families as the health system has failed.”
“When suicide is up to 31 times more likely to occur for someone with an eating disorder, clearly the Government should address this problem with a dedicated focus.”
According to the National Eating Disorders Collaboration (NEDC), an initiative of the Australian Government Department of Health, more than 1 million Australians suffer from eating disorders and represent the third most common chronic illness for young females.
The NEDC also cites research that shows anorexia has the highest death rate of any mental illness and carry a very high rates of mortality with one in 10 people who suffer from an eating disorder dead within 10 years.
Deaths associated with eating disorders are typically caused by medical complications (such as cardiovascular issues and multiple organ failure), suicide or complications relating to substance use.
A 2012 Deloitte Access Economics report examined the economic and social impact of eating disorders in Australia and found the total socio economic cost of eating disorders to be $69.7 billion per year. These costs can be reduced with early detection.
The Australian Medical Association believes that a greater focus is needed on ensuring appropriate access to early intervention and treatment services for young people especially in rural and remote locations. The AMA also believes that a nationally coordinated approach is necessary in order to develop effective and consistent practices in preventing and addressing the incidence of unhealthy body image and eating disorders.
If this article has raised concerns about eating disorders, please contact the Butterfly Foundation national hotline on 1800 33 4673; or visit www.thebutterflyfoundation.org.au for support and resources for eating disorder sufferers and their families and carers.
Meredith Horne
[Comment] Optimising care for children with kidney disease
The theme for World Kidney Day in 2016 was “kidney disease and children: act early to prevent it”. Given the adverse effect of renal replacement therapy—dialysis and transplantation—on quality of life and health care resources, few would disagree with this ambition. For some children, however, end-stage kidney disease cannot be avoided and its effects have to be managed and outcomes optimised. With increasing fiscal pressures on health services in many settings around the world, the Article in The Lancet by Nicholas Chesnaye and colleagues looking at macroeconomics and survival on renal replacement therapy in Europe is timely.
[Comment] Patterns of global health financing and potential future spending on health
Two new Articles in The Lancet1,2 address a very relevant and timely topic in global health economics. In the first Article, Joseph Dieleman and colleagues in the Global Burden of Disease Health Financing Collaborator Network1 use a wealth of data to explore global health financing trends across a 20-year period for a vast number of countries. With adjustment of the data for inflation and purchasing power parity and using non-linear regression methods, the study shows that total health spending is positively correlated with economic development.
Health Financing – building a framework for the long term challenge
BY ASSOCIATE PROFESSOR SUSAN NEUHAUS, CHAIR, HEALTH FINANCING AND ECONOMICS
Health financing is Health Financing and Economics Committee’s (HFE) principal responsibility and central to HFE’s terms of reference. As HFE members will attest, health financing is the largest, most complicated, and all pervasive topic that the committee has the privilege of dealing with.
At its meeting on 1 April 2017, HFE considered the critical elements of current health financing arrangements and the developments and trends likely to impact on those arrangements.
HFE discussed how to build a framework for long term health financing arrangements that are fair, robust and sustainable, and deliver certain and sufficient funding for health care, now and into the future.
This is a challenging task. Health financing is a very complicated policy area. There have been a number of reviews into the system over the years which have discussed (with varying rigour and results) issues surrounding managing costs within components of the health system, with a view to sustainability over the longer term. The overall success of these reviews in terms of lasting, positive improvements has, however, been limited and there have been both overlaps and gaps in their terms of reference.
Public understanding of health financing issues, and the public’s preparedness to consider changes to arrangements for health care, are also limited. Many commentators took this as a key lesson of the 2016 Federal Election. They considered that governments will find it difficult to develop, legislate and implement significant reforms in health without public suspicion of potential impacts on basic Medicare arrangements. Framing a new approach to health financing is clearly not a task for the short-term.
HFE agreed the long-term health financing conversation should be framed in terms of the future health system in 2035. The conversation will need to include all significant stakeholders – organisations and people with a direct interest in the financing of health care, with a view to arriving at a broad consensus on a fair, affordable and sustainable system, and one that takes into account predicted changes in health care needs, advances in medical technology and new information and health management platforms. Consumers should be involved in the conversation.
As a starting point, HFE decided that the AMA could facilitate a discussion around the health system, which could include signalling a number of possible pathways but would not singularly propose a solution.
HFE members noted there is a need to create a space for this discussion that is free of the usual criticisms and stakeholder-positioning that have plagued other reviews and policy processes.
This conversation needs to focus on cost management and obtaining value. It could canvas issues such as whether the health system needs to provide all possible health care to all people at vast and accelerating expense, or should it manage costs by some method.
There needs to be an understanding of the cost drivers going forward, particularly technology and the ageing population, and a national conversation about the level of service we want our health system to deliver in the future.
The conversation should also encompass specific issues identified by HFE members.
These include the need to not only consider efficiency in clinical settings such as hospitals, but also consider efficiency within administration departments, given the growth in these departments within the hospital sector.
Primary health care needs an increased investment, with an understanding of where future pressures and the value of future primary care interventions could be.
The contribution of private health insurance to the overall health system and health financing arrangements also needs to be considered as part of this discussion, particularly given the increasing amount of Government and private spending propping up the industry.
Supporting this work, it would be useful to have a review of the programs run by Government to ascertain which ones are producing good outcomes.
HFE recognised that large-scale change is not likely in the near future. The vision for the future health system must be beyond the three year election cycle. Support from all political parties will be necessary to prevent undermining of solutions.
An important overall outcome of this work should be a ‘vision’ for health financing arrangements that should allow the AMA to be able to hold any Government into the future to account.
The vision also needs to speak to AMA members (and other health care providers) that may be disillusioned or feel abandoned by current arrangements, whether working in general practice, public or private hospitals.
If you have views on how health financing arrangements should change, please contact me. HFE will welcome your input.
Why subsidising private health insurance is a waste
Almost 20 years after the 30% subsidy for private health insurance was introduced, premiums continue to rise every year. This comes at a cost to the federal budget – which was forecast at A$6.5 billion in the 2016 federal budget from the subsidy alone. 
Meanwhile, consumers continue to view private health insurance as poor value for money. It would be sensible for the government to face evidence the subsidy is bad and costly policy, as health bureaucrats and commentators predicted long ago.
Why was private cover subsidised?
The 30% subsidy for private health insurance premiums was introduced in 1999, driven more by media coverage than evidence. Following Medicare’s introduction in 1984, private health coverage had fallen from about 50% of the population in 1985 to just more than 30% in 1998.
Australian Prudential Regulation Authority
The media portrayed this decline as a death spiral that would put unbearable pressure on public hospitals. The public system would no longer be sustainable, the narrative went, as healthy people dropped their private insurance while a pool of sick older individuals with high hospital needs flooded the system.
Evidence for this narrative was flimsy at best, and largely anecdotal. Later analysis demonstrated the insured population was actually a healthier (and richer) subgroup. So, healthier people were maintaining cover, while sicker individuals still relied on the public hospital system.
Yet health ministers under both Labor and Liberal governments became champions of the policy to subsidise private cover. Michael Wooldridge, as health minister in the Howard government between 1996 and 2000, introduced a 30% premium subsidy to those already insured and new entrants.
The subsidy was accompanied by a Medicare Levy Surcharge of 1% of taxable income for higher-income earners (singles with income above A$50,000 and couples above A$100,000) without private cover.
Did premiums fall?
When evidence on private cover emerged, it revealed that the 30% subsidy had a negligible impact on declining levels of coverage. Around 70% of the population preferred to rely on the public system.
Yet the government didn’t question the subsidy, which was already costing A$2.1 billion in 2000-01. Instead it further propped up the private health sector by introducing the lifetime health cover (LHC) policy in 2001.
This was a financial loading that increased by 2% for each year the cover owner was older than 30. It was payable in addition to the base rate premium for any private health insurance hospital cover. Those who purchased before the strict deadline of July 1 avoided the age loading irrespective of their age at entry. After the deadline, only those aged 30 or younger could avoid the loading.
Again the media had a major role. The government funded an advertising blitz across print and electronic media – the Run for Cover campaign – in the lead-up to the deadline in July 2000.
Just days before the deadline, private insurance coverage jumped from 30% to about 45% of the population. Subsequent evidence demonstrated the 50% increase was driven by the scare campaign, not the premiums.
Wooldridge was confident there would be downward pressure on premiums because, under LHC, the pool of insured people were younger, healthier and less likely to make claims on their insurance.
from shutterstock.com
But premiums did not fall. Average private insurance benefits for a hospital episode increased. This was driven by a combination of higher medical fees per service and more services per day in hospital.
What about easing pressure on public hospitals?
While 50% more people had private cover by the end of 2000, public hospitals were largely unaffected. Surgery waiting times remained steady. There were long waits for elective procedures like cataract surgery and knee and hip replacements – as before lifetime health cover was introduced.
For most people, the choice of hospital does not depend solely on private cover, and young adults make few claims. Those who took up private health insurance for financial reasons, such as to avoid the Medicare Levy Surcharge, continued to use the public system much as before. Only a small percentage of the population report they are motivated to buy private hospital cover because they anticipate high health needs.
There is considerable churning, particularly as the young drop their cover. But others approaching the LHC age penalty continue to join, again with media encouragement. Promotion of private cover by the funds focus on extras (renamed “general”) cover (such as dental, optical and chiropractic services) rather than private hospital cover.
The advertising focus is also on younger adults, a group unlikely to claim much in hospital benefits, but more likely to claim for dental, optical and other extras.
But extras cover is more profitable for the funds than hospital cover. For most people, losses exceed benefits. Almost all people with hospital cover combine it with extras. Yet the government subsidy is applied to both hospital and extras cover.
Face the facts
The level of private health coverage remains high; premiums continue to grow driven by higher fees, more services and technology costs; and the budget cost of the subsidy increases with premiums. Insurers claim they cannot control health costs, and the state of the public hospital system is much as before.
Restoring the budget to surplus supports cutting the subsidy, but it seems the political realities place this in the too-hard basket for both government and opposition. Several changes suggest some ambivalence about the policy from government.
Indexation of the rate of subsidy was modified in 2014 and the level of subsidy was income-tested. The effect is to slowly reduce the cost to the public purse.
In addition, the Medicare Levy Surcharge was increased for those on higher incomes, and the LHC loading removed for people who had paid it for ten consecutive years. This was because it was discouraging private cover take-up by older and uninsured consumers.
Some extras items (gym memberships, running shoes) have been removed, and subsidies for natural therapies have been questioned.
Removing the subsidy from extras cover would be a positive move, with significant budget implications. But the case is also clear for going further. While it has been possible to remove subsidies from the car industry (for example), with 45% of the population having private health insurance, removing the flawed subsidy is proving a political challenge.
Elizabeth Savage, Professor of Health Economics, University of Technology Sydney
This article was originally published on The Conversation. Read the original article.
[Articles] Survival, disabilities in activities of daily living, and physical and cognitive functioning among the oldest-old in China: a cohort study
Advances in medications, lifestyle, and socioeconomics might compress activities of daily living disability, that is, benefits of success, but lifespan extension might expand disability of physical and cognitive functioning as more frail, elderly individuals survive with health problems, that is, costs of success.
“Digital Disruption” – Taxis versus Ride-sharing
DOCTOR CLIVE FRASER
Uber ride-sharing arrived in Australia five years ago.
Undoubtedly, it has been popular and a great commercial success, much to the detriment of the established taxi industry.
There were initial issues about the legality of private drivers taking fare-paying passengers, but Governments have bowed to public pressure and have allowed Uber to blossom, and left the taxi industry to wither on the vine.
But I’m right behind the taxi lobby, which is understandably furious about livelihoods being trashed by Uber.
Just a quick look at the economics before driving off shows that taxi owners were paying up to $500,000 for a taxi plate in a highly regulated industry.
Owners of the taxi plates then forked out $50,000 for a Toyota Camry Hybrid with the GPS and cameras for security along with regular safety checks and expensive insurances.
I’ve just spent some time in Melbourne sampling various ways of getting around.
A trip from Richmond to the Tullamarine Airport cost me $75 in a cab.
The driver who owned the cab had no kind words for Uber.
He said the cab would gross about $300 in a 12 hour shift.
The driver kept $165 or 55 per cent of the fares, and with most drivers doing five 12 hour shifts (60 hours per week) the drivers would gross about $825 per week.
After paying for fuel and running costs the Taxi owner kept $80 to $90 per shift.
That’s not a great return for anyone considering the hours worked by the driver and the capital outlay by the owner.
He told me that the cab did about 10,000 kilometres per month and had an annual mechanical inspection.
It was also inspected for safety every time it was serviced every month.
The same trip in an Uber would have cost me $44 to $57, or much, much more if there was surge-pricing in peak demand times.
The Uber owner’s only outlay was $32,000 for a Hyundai i40 diesel and a few dollars per week for an iPhone.
The Uber driver also told me that he worked 60 hours per week, broken up into five hour shifts each morning and five hours each evening, six days per week.
He liked the fact that he could spend most of the day-time at home with his family and he would only drive for Uber when the demand was high.
He told me that he was happy to pick me up because I rated very highly with Uber!
I didn’t have the courage to tell him that my Uber rating was based on an N=1 because I’d only taken a single trip with Uber Black before in Sydney which cost me a small fortune to go from Potts Point to Coogee Beach.
The Uber driver told me that he was driving about 8,000 kilometres per month and that he’d done over 200,000 kilometres in the Hyundai i40 in the past two years.
He’d bought the Hyundai because it had a five-year unlimited kilometre warranty and he was fairly sure he wouldn’t be spending anything on the car other than basic service items.
He told me that he made about $2,000 per week doing Uber (minus $120 for fuel plus other vehicle running costs).
At this point in the chaotic world of digital disruption I decided to take a reality check and Google the fine print of Hyundai’s five-year warranty which said that: “Hyundai warrants against defects arising in materials or manufacture for all vehicles other than vehicles used at any time during the warranty period for commercial application.”
I wondered whether the good people at Hyundai would regard an Uber ride-share (aka taxi) as a “commercial application”.
I also thought it was best not to ask about insurance as I was a fare-paying passenger in a private vehicle.
I was after all trusting my safety/livelihood/career into the hands of a total stranger.
I decided definitely not to raise any of these concerns with the Uber driver lest he gave me a bad review which would immediately halve my rating as N would then equal 2 and I might be left by the road-side from now on.
Whilst I’m all for the free-market and competition, unlike many of my colleagues I haven’t fallen in love with Uber.
Safe motoring,
Doctor Clive Fraser