We’re seeing more casual COVID transmission. But is that because of the variant or better case tracking?

Catherine Bennett, Deakin UniversityVictoria’s lockdown is to be extended for another week to get on top of the growing number of community cases, which now stands at 60.

But questions remain about what’s behind some of these cases.
Victoria’s COVID-19 testing commander Jeroen Weimar said yesterday in about four or five cases, the virus was transmitted after only “fleeting contact”.

Today, we heard from Victoria’s Chief Health Officer Brett Sutton about one case suspected to have been infected when visiting a site some two hours after an infectious person had left. The source case had been there for some time, and it was described as a poorly ventilated space.

Nonetheless, this is consistent with the aerosol transmission we have become increasingly concerned about, and perhaps this is the first documentation of this outside hotel quarantine.

Today we also heard that health authorities have reported about 10% of cases are linked with more casual exposures, including at “tier two” sites (Victoria describes exposure sites according to risk, with a tier one site being the most risky).

So is it the virus, or more focused efforts in tracking cases, that’s led us to finding such casual exposures?

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What can you expect if you get a call from a COVID contact tracer?

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Is it the virus?

Despite today’s news, people are not more likely now to get infected by brushing past someone on the street.

In the vast majority of cases, people have become infected by very close contacts, or at certain “tier one” exposure sites when there at the same time as a known case.

There is evidence the variant associated with India is more infectious. This particular lineage of the Indian variant B.1.617.1, however, may not be as infectious as other lineages.

It reinforces how important it is that outbreaks are contained as early as possible where this increased risk of spread is still manageable.

On average, with variants of concern like the one currently circulating in Victoria, a case might infect 15% of household contacts instead of 10% seen in 2020. When new case numbers are high later in an outbreak, this difference in transmission translates to much bigger jumps in case numbers.

The way the virus spreads in clusters has also not changed, with some cases not passing the virus on, while a small number pass it on to many.

If this strain of the virus were vastly more transmissible than the original strain, we’d expect to see many cases. This strain has been in our community for a month now, undetected and running free for more than two weeks. There would be many more than 60 cases if this were true.

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What’s the ‘Indian’ variant responsible for Victoria’s outbreak and how effective are vaccines against it?

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We’re also better at tracking cases

The main thing that’s changed since Victoria’s second wave last year is that we have forensic analysis of every case and we’re better at finding casual links between cases.

We’re now publishing lists of venues with exposure times and more people are coming forward for testing than at the peak of Victoria’s second wave. We also have check-in data for many venues.

This results in more reliable measures of both the total spread and routes of virus transmission, than in the second wave, or any community outbreak of this size.

Transmission associated with more casual exposures would have been much more likely to be missed before. Even if these cases were picked up, they might have been counted among the “mystery cases” that comprised 18% of all cases in 2020. We didn’t know where these cases were infected as there were no apparent links between them and known cases.

We are doing much better this time with only three transmission events that not yet fully understood.

How about this ‘fleeting contact’?

The four or five cases Weimar mentioned yesterday relate to a range of indoor exposure sites including a display home, a Telstra shop, local grocery stores, and a shopping strip.

This is where people may have been in direct contact with a case, but where no definitive exposure event is documented, there is no check-in and people don’t know each other.

So from what we know so far, there’s been a crossover between when most cases were present and where their contacts became infected. And 90% of these are in the settings we know are high transmission risk — households and workplaces in particular, where there is extended and repeated indoor contact.

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Australia has all but abandoned the COVIDSafe app in favour of QR codes (so make sure you check in)

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The more casual contacts described yesterday, in a display home or at the Telstra shop, there might have been some overlap with a case in a small enclosed area for sufficient time to receive an infecting dose.

A further example Sutton provided today was an infection that started with someone sitting in the same outdoor area as a case at a hotel bistro. We know there is less risk in outdoor settings generally, but on a still autumn day, we now know this is all it takes.

Now, as we have transmission in the beer garden, all those nearby will be recategorised as primary close contacts and asked to quarantine for a full 14 days, even if they have returned a negative test. Better to be safe than sorry.

That’s why it’s so important to check in with a QR code. You don’t always know the name of the person who’s standing (or sitting) next to you. It is also why check-ins will now be required at more retail and public venues across the state. Being able to identify contacts in these settings will remove some of the fear associate with this more casual spread.

So what are we to make of this?

This latest news reinforces the importance of QR codes and checking in. You never know who you’re standing next to in a long queue while shopping.
Extending our QR codes into further settings whether retail, grocery stores or display homes, which we now know are a risk, is a good move.

The message remains the same, get tested if you have symptoms or when directed to by public health officials, and isolate when necessary. In particular, keep an eye on those exposure sites, even if you only dropped in to grab a coffee.

But we shouldn’t be overly concerned about COVID-19 spread by “fleeting contact”. The precautions we all know (hygiene, distancing and masks) still work and are our best forms of protection.

Catherine Bennett, Chair in Epidemiology, Deakin University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Budget package doesn’t guarantee aged-care residents will get better care

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Stephen Duckett, Grattan Institute and Anika Stobart, Grattan InstituteThe big investment in aged care announced in last night’s federal budget – an extra A$17.7 billion over five years – is a welcome response to the Royal Commission into Aged Care Quality and Safety. But even an investment of this scale does not meet the level of ambition set by the royal commission.

The government has committed A$6.5 billion for more home-care packages (about A$2.5 billion more for home care per year when fully implemented), and A$7.1 billion for residential-care staffing and services (about $2.4 billion more for residential care per year when fully implemented).

But the government has failed to outline a clear vision of what older Australians should expect of their aged-care system.

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Fewer hard hats, more soft hearts: budget pivots to women and care

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Immediate fixes with no guarantees

The budget includes funding for 80,000 extra home-care packages over two years. The current home-care packages program has numerous problems, including nearly a 100,000-strong waiting list.

But the government has not explicitly promised to clear the waiting list and bring waiting times down to 30 days, as the royal commission called for.

The budget has some good news for people in residential aged care. The Basic Daily Fee (for services including food) will be increased by A$10 per resident per day, as called for by the royal commission.

And there’s more funding for better staffing, with mandates for an average of at least 200 minutes of care for every resident every day (40 minutes of which must be by a nurse) by 2023.

This is a good start, given nearly 60% of residents presently get less than this. But residents will have to wait two years – not one, as recommended by the royal commission – before they get more care hours.

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If we have the guts to give older people a fair go, this is how we fix aged care in Australia

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The budget also provides additional funding to improve the aged-care workforce. The government will subsidise the training of new and existing aged-care workers, including 33,800 places to attain Certificate III.

But the government has not gone far enough in supporting the workforce. It stopped short of guaranteeing that every staff member providing care for older Australians will be trained to a minimum Certificate III level, and that all residential aged-care facilities will have a registered nurse on site 24 hours a day.

The budget commitments appear to be a once-off, with workforce funding plummeting to only A$86.5 million in 2024-25, compared to A$293.3 million in 2022-23. And there is no commitment to lift carers’ wages.

Residents won’t have access to a registered nurse 24 hours a day.
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Small steps towards a better system

The royal commission made it clear the aged-care system needed to be reformed from top to bottom. The government’s announcements foreshadow a shake-up of the system over five years. But the extent of reform is yet to be determined.

The budget papers show funding will be up by about A$5.5 billion per year once most reforms are in (see the chart below). That’s not enough to create a needs-driven, rights-based system, called for by the royal commission and the Grattan Institute.

Federal budget paper 2

The government has committed to a new Aged Care Act, to be legislated by mid-2023, though the details are yet to be filled in. This Act must put the rights of older Australians at its heart.

The government has also committed to designing a new home care program and will provide a single assessment process for both home care and residential care.

More home-care packages will be available but there won’t be enough for all those currently on the wait list.
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A local network of health department staff will be embedded in the regions, and there will be a network of 500 “care finders” to help older Australians get the support they need.

But the biggest risk to achieving real structural change is governance and transparency. Here, the government has fallen short.

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4 key takeaways from the aged care royal commission’s final report

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The government does not support the establishment of an independent aged care commission. Most disappointingly, it is pumping A$260 million into the Aged Care Quality and Safety Commission, which the royal commission found had demonstrably failed.

While some transparency will be provided through public reporting of staffing hours and star ratings to compare provider performance, clear transparency measures will be needed to ensure the additional billions don’t end up boosting providers’ profits.

The good news from budget 2021 is that the journey has begun. The government has made a substantial down payment to allow development of a new aged-care system. We must hope that more will follow, so the neglect ends and every older Australian can get the care and support they need.

Stephen Duckett, Director, Health Program, Grattan Institute and Anika Stobart, Associate, Grattan Institute

This article is republished from The Conversation under a Creative Commons license. Read the original article.

7 ways to better design quarantine, based on what we know about human behaviour

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Holly Seale, UNSW

When we hear of people who have allegedly escaped from mandatory quarantine — whether that’s from hotels in Perth, Toowoomba, Sydney or Auckland — it’s easy to ask: “What were they thinking? Why didn’t they just follow the rules?”.

But our recent review shows people are less likely to follow public health advice if they misunderstand, or have negative attitudes towards it.

The challenge is that while COVID-19 has been with us since the beginning of the year, we still may not necessarily know someone in our close networks who has been in quarantine. We may be relying on a deluge of misinformation about it from the media, or social media.

So how can we use our knowledge of human behaviour to better support people complying with quarantine?

Which factors affect what we think about quarantine?

We reviewed the range of factors that influence people’s engagement or compliance with COVID-19 public health advice, such as quarantine. These included:

• perceptions around the rationale and effectiveness of quarantine

• perceived consequences of complying (or not)

• perceptions about the level of community and personal risk from COVID-19

• having enough basic supplies (for instance, food, water, clothes).

Gender, age, marital status, professional status and education level also played a role in whether people complied, but clearly, these cannot be modified.

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Another day, another hotel quarantine fail. So what can Australia learn from other countries?

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The facts are important, but so are emotions

Our review found one of the major factors affecting people’s likelihood to comply with quarantine is their knowledge about COVID-19, how the virus is transmitted, symptoms of infection, and quarantine protocols.

Not understanding what quarantine means and its purpose may lead to people inventing their own rules, based on what they think is an acceptable degree of contact or risk.

Perhaps not too surprising, if we believe quarantine is beneficial, then we are more likely to follow the rules. However, providing people with merely factual information may not be the answer. We need to engage with people’s emotions too.

Emotions can influence our perception of risk, sometimes more so than factual information. For example, we often hear about the negative experiences of quarantine or self-isolation, but often not the positive frame, for instance the number of people who have successfully complied. This helps normalise quarantine, and make people more likely to copy the expected behaviour.

If we think it’s normal to stick to the rules and doing so is in the collective good, then we’re less likely to muck up.
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Social norms play an important role. If people believe there is a collective commitment to protect the community from further spread of infection, they are more likely to respect the public health measure. An individual’s participation can be conditional on whether they think others are also contributing.

However, social norms can also have the opposite effect. If people think others are breaking the quarantine rules, they may follow suit.

Concerns about stigma or discrimination can also impact a person’s willingness to comply with quarantine. Stigma can make people more likely to hide symptoms or illness, keep them from seeking health care immediately, and prevent people from adopting healthy behaviours.

Lastly, people may push back against the regulations as a way of retaining a feeling of control. They may push back because they are stressed or anxious, which in turn affects how they think about the issue or how they make decisions.

So how do we use this?

To support acceptance of and community compliance with quarantine, we need to take these behavioural issues into account. We need to:

1. prepare people for what they might experience: boredom, loss of freedom or routine, irritability and/or anxiety. Priming people may help them think about ways to reduce these issues

2. encourage people to make plans as we know this helps people cope. Encouraging people to stick to similar (pre-quarantine) routines may help people avoid getting anxious or stressed. These plans need to be time-specific and intentional, not aspirational. For instance, we could encourage people to structure time for exercise and for virtual socialising. Others have suggested doing shared activities, such as watching a movie on Netflix at the same time

3. provide access to social, pyschological and medical support whether that’s via reliable internet access or access to helplines

4. provide adequate basic supplies such as food, water and clothes, and a safe and clean place to quarantine

5. encourage our leaders to clearly articulate, and others to reinforce, that complying with quarantine is in our group interest and it’s expected people will pull their weight. And if they don’t, this won’t be acceptable

6. provide media coverage that reflects the fact most people comply. Examples of people who run away from quarantine clearly represent quarantine failures, but they are outliers. Perhaps its time to look at the proportion of people who have complied with hotel quarantine as we need to establish the collective norm is to comply

7. provide people with adequate sick leave and other structural supports, such as the ability to work remotely, alongside any solutions supporting behaviour change.

Holly Seale, Senior Lecturer, UNSW

This article is republished from The Conversation under a Creative Commons license. Read the original article.

In praise of the office: let’s learn from COVID-19 and make the traditional workplace better

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Geoff Plimmer, Te Herenga Waka — Victoria University of Wellington; Diep Nguyen, Edith Cowan University; Esme Franken, Edith Cowan University, and Stephen Teo, Edith Cowan University

Having had to rapidly adjust to working from home due to COVID-19, many people are now having to readjust to life back in the office. Many will have enjoyed aspects of what is sometimes called “distributed work”, but some may be dreading the return.

So is there a middle ground? Could hybrid work arrangements, known for boosting well-being and productivity, be a more common feature of workplaces in the future?

We say yes. Organisations need to recognise the valuable habits and skills employees have developed to work effectively from home during the lockdown. But they will need good strategies for easing the transition back into the physical workplace.

In doing so, they should aim for the best of both worlds — the flexibility of distributed work and the known benefits of the collaborative workplace.

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The death of the open-plan office? Not quite, but a revolution is in the air

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Good riddance to hot-desking

A good start would be a proper re-evaluation the two worst aspects of office life: crowded open-plan designs and so-called “hot-desking”.

Cramped shared offices and free-for-all hot-desking are both known for their negative impacts on quality of workplace life. The results are often interpersonal conflict, reduced productivity and higher rates of sickness.

Some organisations have already done away with hot-desking in an effort to improve physical and mental well-being. Acknowledging the evidence that tightly packed, cost-saving, open-plan office arrangements have not delivered what was promised should be another priority.

Hopefully, the impact of COVID-19 on business as usual will spell the end of these often poorly thought through management fads.

Work-life imbalance: how do companies help their employees and also boost productivity?
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Working from home can be isolating

At the same time, there is no need to throw the baby out with the bathwater. The office still has its advantages, and there is research showing that working from home has clear disadvantages for employees and organisations when it is offered as a permanent arrangement.

One study involved a large (anonymous) US Fortune 100 technology firm. It began as a traditional survey of what it was like for individuals to work from home, but evolved into a study of the effect of what happened to the company’s community when working from home was normalised.

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The research on hot-desking and activity-based work isn’t so positive

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The option of unrestricted distributed work meant employees simply stopped coming to work at the office. Many reported the well-known benefits of working from home, such as work-life balance and productivity.

They also reported a kind of “contagion effect”. As colleagues began to stay at home a tipping point arrived where fewer and fewer people opted to work in the office.

But this actually increased a sense of isolation among employees. It also meant the loss of opportunities to collaborate through informal or unplanned meetings. The chance to solve problems or be given challenging assignments were lost as well.

Those who participated in the study said social contact and productively interacting with colleagues was the main reason they wanted to come to work. Without it there was no real point. The research raises the possibility of a net loss in well-being if everyone were to work remotely.

Well-being and job satisfaction depend on a range of factors, including having clear goals, social contact and the structure of the traditional working day. Of course, jobs can also be toxic if there is too much structure. But fully distributed work may not provide the support, identity and community that offices provide for some.

Nor is technology always adequate when it comes to the subtle value of face-to-face catch ups. Five minute water-cooler talks and post-meeting debriefs still matter for both productivity, social contact and cohesion.

A different kind of management: motivating and maintaining morale in a distributed workplace requires new skills.
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Management has to adapt too

None of which is to suggest there are not identifiable advantages of distributed work and the flexible workplace. As many of us discovered during the lockdown, just avoiding the daily commute helped with lowering stress and better work-life balance. Choosing when we worked was attractive too.

But this requires better management skills. Distributed workers require different (often better) engagement strategies, including the ability to build mutual trust.

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Working from home: what are your employer’s responsibilities, and what are yours?

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Research into how best to manage the health and safety of distributed workers has found that some leaders simply can’t adapt to the digital environment. Trust, consideration and communicating a clear vision or sense of purpose matter more for distributed workers than for those in the traditional office.

Recognition, reward, development and advancement in a distributed working environment will all need special attention. So too will ways to deal with people not pulling their weight, maybe because of too much time on social media.

Even the simple benefits of spontaneous humour in meetings or informal team interactions are easily lost with “e-leadership”, so new ways of building and maintaining morale are vital.

This is not an either/or question. Rather, the challenge is to strike a new balance — how to retain the benefits of distributed work while maintaining the sense of community that comes from personal interaction in the office.

Geoff Plimmer, Senior lecturer in Human Resource Management, Te Herenga Waka — Victoria University of Wellington; Diep Nguyen, Lecturer, Edith Cowan University; Esme Franken, Lecturer in Management, Edith Cowan University, and Stephen Teo, Professor of Work and Performance, Edith Cowan University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Does hitting the snooze button really help you feel better?

How many times do you hit snooze before getting out of bed?
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Steven Bender, Texas A&M University

To sleep or to snooze? You probably know the answer, but you don’t prefer it.

Most of us probably use the snooze function on our alarm clocks at some point in our lives. Just a few more minutes under the covers, a time to gather our thoughts, right?

While such snoozing might seem harmless, it may not be. For starters, it is important to understand why we are using the snooze button in the first place. For some it’s a habit that started early on. But for many, it can signal a significant problem with sleep. Poor sleep has been shown to be associated with a number of health disorders including high blood pressure, memory problems and even weight control.

I’m a facial pain specialist and have extensively studied sleep and how it impacts painful conditions. With testing, we discover that many of our chronic pain patients also suffer with various sleep disorders.

What does normal sleep look like?

If one is tired when the alarm goes off, is it helpful to use the snooze button? While there are no scientific studies that address this topic specifically, the answer is probably not. Our natural body clock regulates functions through what’s known as circadian rhythms – physical, mental and behavioral changes that follow a daily cycle.

Most adults require approximately seven and a half to eight hours of good sleep per night. This enables us to spend adequate time in the stages of sleep known as nonrapid eye movement sleep (NREM) and rapid eye movement sleep (REM).

We tend to cycle from the three stages of NREM into REM sleep four to six times per night. The first portion of the night is mostly NREM deep sleep and the last portion consists of mostly REM sleep.

The stages of sleep.
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Good sleep is important

Maintaining this well-defined structure is important for good, restful sleep. If this process is disturbed, we tend to awaken still feeling tired in the morning.

A number of factors can affect the sleep cycles. For example, if a person is not breathing well during sleep (snoring or sleep apnea), this will disturb the normal sequences and cause the individual to awaken feeling unrestored. Sleep quality can be diminished by the use of electronic devices, tobacco or alcohol in the evening. Even eating too close to bedtime can be problematic.

The use of snooze buttons often starts during the teenage years, when our circadian rhythms are altered somewhat, causing us to want to stay up later and get up later in the morning. Delaying getting out of bed for nine minutes by hitting the snooze is simply not going to give us any more restorative sleep. In fact, it may serve to confuse the brain into starting the process of secreting more neurochemicals that cause sleep to occur, according to some hypotheses.

Bottom line: It’s probably best to set your alarm for a specific time and get up then. If you are consistently tired in the morning, consult with a sleep specialist to find out why.

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Steven Bender, Clinical Assistant Professor of Oral and Maxillofacial Surgery, Texas A&M University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Anxieties over livestreams can help us design better Facebook and YouTube content moderation

Livestream on Facebook isn’t just a tool for sharing violence – it has many popular social and political uses.
glen carrie / unsplash, CC BY

Andrew Quodling, Queensland University of Technology

As families in Christchurch bury their loved ones following Friday’s terrorist attack, global attention now turns to preventing such a thing ever happening again.

In particular, the role social media played in broadcasting live footage and amplifying its reach is under the microscope. Facebook and YouTube face intense scrutiny.

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Social media create a spectacle society that makes it easier for terrorists to achieve notoriety

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New Zealand’s Prime Minister Jacinda Ardern has reportedly been in contact with Facebook executives to press the case that the footage should not available for viewing. Australian Prime Minister Scott Morrison has called for a moratorium on amateur livestreaming services.

But beyond these immediate responses, this terrible incident presents an opportunity for longer term reform. It’s time for social media platforms to be more open about how livestreaming works, how it is moderated, and what should happen if or when the rules break down.

Increasing scrutiny

With the alleged perpetrator apparently flying under the radar prior to this incident in Christchurch, our collective focus is now turned to the online radicalisation of young men.

As part of that, online platforms face increased scrutiny and Facebook and Youtube have drawn criticism.

After dissemination of the original livestream occurred on Facebook, YouTube became a venue for the re-upload and propagation of the recorded footage.

Both platforms have made public statements about their efforts at moderation.

YouTube noted the challenges of dealing with an “unprecedented volume” of uploads.

Although it’s been reported less than 4000 people saw the initial stream on Facebook, Facebook said:

In the first 24 hours we removed 1.5 million videos of the attack globally, of which over 1.2 million were blocked at upload […]

Focusing chiefly on live-streaming is somewhat reductive. Although the shooter initially streamed his own footage, the greater challenge of controlling the video largely relates to two issues:

1. the length of time it was available on Facebook’s platform before it was removed
2. the moderation of “mirror” video publication by people who had chosen to download, edit, and re-upload the video for their own purposes.

These issues illustrate the weaknesses of existing content moderation policies and practices.

Not an easy task

Content moderation is a complex and unenviable responsibility. Platforms like Facebook and YouTube are expected to balance the virtues of free expression and newsworthiness with socio-cultural norms and personal desires, as well as the local regulatory regimes of the countries they operate in.

When platforms perform this responsibility poorly (or, utterly abdicate it) they pass on the task to others — like the New Zealand Internet Service Providers that blocked access to websites that were re-distributing the shooter’s footage.

People might reasonably expect platforms like Facebook and YouTube to have thorough controls over what is uploaded on their sites. However, the companies’ huge user bases mean they often must balance the application of automated, algorithmic systems for content moderation (like Microsoft’s PhotoDNA, and YouTube’s ContentID) with teams of human moderators.

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A guide for parents and teachers: what to do if your teenager watches violent footage

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We know from investigative reporting that the moderation teams at platforms like Facebook and YouTube are tasked with particularly challenging work. They seem to have a relatively high turnover of staff who are quickly burnt-out by severe workloads while moderating the worst content on the internet. They are supported with only meagre wages, and what could be viewed as inadequate mental healthcare.

And while some algorithmic systems can be effective at scale, they can also be subverted by competent users who understand aspects of their methodology. If you’ve ever found a video on YouTube where the colours are distorted, the audio playback is slightly out of sync, or the image is heavily zoomed and cropped, you’ve likely seen someone’s attempt to get around ContentID algorithms.

For online platforms, the response to terror attacks is further complicated by the difficult balance they must strike between their desire to protect users from gratuitous or appalling footage with their commitment to inform people seeking news through their platform.

We must also acknowledge the other ways livestreaming features in modern life. Livestreaming is a lucrative niche entertainment industry, with thousands of innocent users broadcasting hobbies with friends from board games to mukbang (social eating), to video games. Livestreaming is important for activists in authoritarian countries, allowing them to share eyewitness footage of crimes, and shift power relationships. A ban on livestreaming would prevent a lot of this activity.

We need a new approach

Facebook and YouTube’s challenges in addressing the issue of livestreamed hate crimes tells us something important. We need a more open, transparent approach to moderation. Platforms must talk openly about how this work is done, and be prepared to incorporate feedback from our governments and society more broadly.

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Read more:
Christchurch attacks are a stark warning of toxic political environment that allows hate to flourish

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A good place to start is the Santa Clara principles, generated initially from a content moderation conference held in February 2018 and updated in May 2018. These offer a solid foundation for reform, stating:

1. companies should publish the numbers of posts removed and accounts permanently or temporarily suspended due to violations of their content guidelines
2. companies should provide notice to each user whose content is taken down or account is suspended about the reason for the removal or suspension
3. companies should provide a meaningful opportunity for timely appeal of any content removal or account suspension.

A more socially responsible approach to platforms’ roles as moderators of public discourse necessitates a move away from the black-box secrecy platforms are accustomed to — and a move towards more thorough public discussions about content moderation.

In the end, greater transparency may facilitate a less reactive policy landscape, where both public policy and opinion have a greater understanding around the complexities of managing new and innovative communications technologies.

Andrew Quodling, PhD candidate researching governance of social media platforms, Queensland University of Technology

This article is republished from The Conversation under a Creative Commons license. Read the original article.

More visits to the doctor doesn’t mean better care – it’s time for a Medicare shake-up

The number of Medicare claims Australians make in a year doubled between 1984 and 2018.
By Sopotnick

Jane Hall, University of Technology Sydney and Kees Van Gool, University of Technology Sydney

This is part of a major series called Advancing Australia, in which leading academics examine the key issues facing Australia in the lead-up to the 2019 federal election and beyond. Read the other pieces in the series here.

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Over the last 35 years, Medicare has given Australians access to high-quality health care at a reasonable cost. But, despite our justifiable pride in Medicare, it’s time to reconsider the way we pay for health care.

Australia’s Medicare system is a A$20 billion-a-year program. It subsidises most of our out-of-hospital doctor consultations, blood tests, X-rays and scans, physio appointments, eye tests and many other health services. It’s based on a long list of items and each time an item is provided, Medicare pays a benefit.

But paying doctors and other health providers a set fee for each service they deliver is not delivering optimal value for the health dollar. There are two reasons for this.

First, it encourages a higher volume of services, but not necessarily better-value services.

Second, it constrains doctors into delivering the care based on the items in the schedule, which often don’t meet the needs of complex patients.

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Explainer: what is Medicare and how does it work?

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One promising alternative is “bundled payments”. Rather than paying doctors a “fee for service”, they would be paid a prospective lump sum to care for the patient’s medical problem, over a specified period.

The lump sum would be a pooled payment for all services provided to treat the condition. The provider’s role would be to coordinate the patient’s care across different parts of the health system and work with a range of health professionals to deliver high-quality care.

This would give doctors greater flexibility to manage the care patients need. At the same time, doctors would be held accountable via measurements of the quality of their care.

Importantly, this would give patients greater access to a broader range of services and make it easier to navigate our complicated health system.

Why health costs are rising

Between 1984 and 2018, Australian government spending on services outside of hospitals has increased from A$426 to A$818 per person, after adjusting for inflation.

This increase is almost entirely due to service volume. Back in 1984, the average Australian made 7.25 out-of-hospital Medicare claims a year. By 2018, this had escalated to 15.34; a doubling in the average number of claims.

The biggest growth has been in the number of pathology claims for blood and tissue tests (1.4 in 1984 to 5.2 in 2018), followed by GP consultations (4.2 compared to 6.3) and diagnostic imaging, including X-rays and other types of scans (0.3 versus 1.0).

This is not just the result of population ageing. At every age, we are making more Medicare claims. In 1985, people aged between 75 and 84 made 16.1 Medicare claims per year. In 2018, this number had grown to 44.6 claims per person per year.

Medicare prices have been very steady. For GP consultations, for example, the benefit paid per service has increased by 72% over the 35-year period, and mostly as a direct result of policy initiatives such as the Strengthening Medicare reforms introduced in 2004-05.

In fact, since 2005, the benefit per service has declined by 6% in real terms. This is a result, in part, of the Medicare freeze imposed by government between 2012 and 2018.

So price control is only one part of constraining expenditure growth. The other is the volume of services.

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Read more:
FactCheck: has Medicare spending more than doubled in the last decade?

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The medical care market has undergone considerable corporatisation. Corporate entities now own around 10% to 15% of all GP practices in Australia.

Corporate entities can own and run primary care practices as well as pathology laboratories, diagnostic imaging services and even pharmacies. This creates more incentive to refer patients to their own businesses for blood tests and imaging to increase the volume of claims, and therefore increase profits.

Greater spending doesn’t mean better care

The second critique of Medicare is that current funding arrangements create disincentives for delivering optimum care over a longer period, particularly for complex patients who require multiple services from multiple providers. They might have cancer, for instance, or multiple chronic diseases such as heart disease and diabetes or dementia.

Currently, Medicare makes a payment for every claim made within what we call an “episode of care” – a set of services to treat a condition, or a procedure. Each provider in that episode has an incentive to increase their own volume of care, but there are virtually no incentives to coordinate or deliver an optimum pathway of care for the patient.

Further, there are too few opportunities and rewards in this system to give doctors flexibility to offer different types of care for patients. This includes care provided by nurses, physiotherapists or dietitians; email or telephone consultations; patient education; and coordination services.

Instead, pay doctors a lump sum

The main feature of a good payment system is that it creates the right incentives for providers and patients to use health care resources effectively, efficiently and equitably.

Bundling payment involves working out the best care pathways for each condition. Cancer, for example, is a complex disease that requires ongoing care from primary, specialist and hospital services.

Under a bundled payment, the patient’s GP clinic would be paid a lump sum to ensure the patient receives all the services they need. This includes consultations, health checks, blood tests, physiotherapy, dietetics, patient education, and so on. The GP would have more control over how each of those services is delivered.

Sometimes will be best cared for by a physiotherapist.
Africa Studio/Shutterstock

If viable, the GP could bring some of these services into their practice, or they could subcontract them to other organisations.

The practice would be held accountable for providing high-quality care through various performance measures. These could range from patient satisfaction measures to objective measures such as timeliness of care or fewer avoidable complications. Payments could, in part, be made conditional on meeting performance targets.

Ultimately, because we are giving the provider more say over how care is delivered, the model of care can be more easily adapted to the needs of the patient.

Health reform must be based on evidence

In the small number of countries where bundled payments have been piloted, they are associated with improved quality, financial savings and increased patient satisfaction.

A bundled payment for hip-fracture patients in England, for example, resulted in more patients receiving surgery within 48 hours after admission and lower death rates.

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Read more:
Creating a better health system: lessons from England

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Although these studies show promise, the evidence base is still in its infancy.

Successful reform in this area will require careful design of the bundles, the payment levels and patient selection process, as well as how best to monitor quality care. In particular it requires robust evidence to determine:

• what constitutes an optimal bundle of care for a particular condition
• the cost of delivering those services
• how the payment should be adjusted for the specific characteristics of a patient
• the role performance targets may play in motivating health providers to deliver high-quality care.

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Read more:
Is it time to ditch the private health insurance rebate? It’s a question Labor can’t ignore

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Jane Hall, Professor of Health Economics and Director, Centre for Health Economics Research and Evaluation, University of Technology Sydney and Kees Van Gool, Health economist, University of Technology Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Voters are crying out for better government but have mixed views on how to achieve it

When government policy turns out to be a dud and goes off the rails, no one is happy.
Shutterstock

Nicholas Biddle, Australian National University and Matthew Gray, Australian National University

Support for democracy and trust in politicians is falling. We hear a lot about evidence-based policy as a way to stem this decline, but less about how that evidence should be generated.

One idea that may generate the type of evidence that will help make more informed decisions appears, paradoxically, fairly unpopular with the punters.

Perhaps the problem is that not enough has been done to explain to the public what this idea – carefully testing new policies on small groups first – might mean in practice.

In a new paper just released, we show that we may still be a long way off adopting this practice.

The rollout of the National Broadband Network has been plagued by delays, changes of plan and consumers unhappy with the end result.
Mark Esposito/AAP

There is an emerging view that there should be much greater use of evaluations of public policies, including randomised controlled trials (RCTs), to test the effectiveness of new policies before they are rolled out. This applies particularly to policies or programs for which there is limited or no evidence about their likely impact.

RCTs have been around for years in medicine and other sciences, and are increasingly being used by small and large companies to test products and services. Conceptually they are simple, although implementing one can be complex. A RCT involves selecting a sample from a population of interest and randomly dividing them into two groups (using the equivalent of a coin toss). One group is given an intervention (that is, a program or policy) and the other is not. If the RCT has been done properly, the differences in the outcomes of the two groups tells us the impact of the intervention being trialled.

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The heart of the matter: how effective is the flu jab really?

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There are other ways to try to measure causation, and some are necessary when an RCT isn’t possible. However, Shadow Assistant Treasurer Andrew Leigh argues in his new book Randomistas that:

Researchers have spent years thinking about how best to come up with credible comparison groups, but the benchmark to which they keep returning is the randomised controlled trial. There’s simply no better way to determine the counterfactual than to randomly allocate participants into two groups: one that gets the treatment, and another that does not.

Our study

While there is strong support within the policy and research community on the important role of trials and evaluations, we know far less about what the general public thinks about how policies should be implemented and to what extent they should be trialled before widespread introduction.

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Read more:
From ‘trust us, we’re doctors’ to the rise of evidence-based medicine

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In a survey undertaken as part of the ANUPoll series, we ran an online survey experiment that measured the level of support for trials in general and RCTs in particular. We also looked at the factors that influence that support, and whether there is a causal relationship between expert opinion, party identification and support for an RCT.

That is, we ran an RCT on RCTs.

As part of the survey, we asked respondents to “consider a hypothetical proposal to reform” in one of five policy areas (school education; early childhood education; health; policing; support for those seeking employment). We then asked “which of the following approaches do you think the government should take?”:

• Introduce the policy for everyone in Australia at the same time
• Introduce the policy to everyone, but do it in stages
• Trial on a small segment of the population who need it most, or
• Trial on a small segment of the population chosen randomly,

We found that more people want new government policies rolled out without testing – except for jobless support.

Some key findings emerge:

• There is a roughly even split between those who think a new policy should be introduced to everyone at once and those who think it should be trialled on a small segment of the population.

• Respondents support trials for employment policies the most strongly but are most likely to support an RCT for a policy related to school education. They are least likely to support it for health service delivery and employment support.

• Those who live in disadvantaged areas and those with low levels of education are the least supportive of RCTs.

What influence do experts’ views have?

The type of policy that is being proposed clearly matters for whether the general public thinks it should be trialled as part of an RCT. However, the views of those outside the political system also matter. We tested this potential effect by randomly varying the wording of the question across respondents.

One “treatment” that we applied to the question was to vary what respondents were told on whether experts generally support the policy, are generally opposed to the policy, or are divided on the policy (with one-third of respondents given each of the options).

Randomised controlled trials are commonplace in the area of medical products – after all, we all feel better knowing a new product has been thoroughly tested.
AAP

The greatest support for a trial in general or an RCT in particular occurs when experts are generally opposed to the policy. Conversely, the least support for a trial or an RCT comes when experts are generally in support of the policy, implying respondents believe sufficient evidence must already exist. Support is somewhere in between when there is variation in support.

This has implications, we think, for researchers engaged in policy debates. One potential effect of arguing publicly for a different point of view to policymakers or other researchers is to increase the level of support for trials among the general population. We should make a case for uncertainty when it does exist, as that would appear to increase support for future gathering of evidence.

Indeed, this advocacy for uncertainty has underpinned the push for greater trials and evaluations in policy (and the social sciences).

Building support

It is clear that RCTs are likely to be increasingly used by policymakers to test the effect of policy interventions. However, to be truly effective and to avoid a backlash, RCTs need to be supported not only by researchers and policymakers but also by the general public. At first glance, this buy-in is a long way off.

Nicholas Biddle, Associate Professor, ANU College of Arts and Social Sciences, Australian National University and Matthew Gray, Director, ANU Centre for Social Research and Methods, Australian National University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Latest Persecution News – 16 June 2012

Gutted Church Building Leaves Egyptian Copts with Debt

The following article reports on the latest news of persecution in Egypt.

http://www.compassdirect.org/english/country/egypt/article_1602720.html

 

Christians Hail Dissolution of Egyptian Parliament

The following article reports on the political crisis in Egypt and Christian hopes for better days ahead.

http://www.compassdirect.org/english/country/egypt/article_1603044.html

 

The articles linked to above are by Compass Direct News and  relate to persecution of Christians around the world. Please keep in mind that the definition of ‘Christian’ used by Compass Direct News is inclusive of some that would not be included in a definition of Christian that I would use or would be used by other Reformed Christians. The articles do however present an indication of persecution being faced by Christians around the world.

Counting the Numbers: A Hopeful Sign of Some Change

The article below is about one megachurch pastor in the United States and his questioning of marketing values in the church today. I think there are some hopeful signs in his comments, but there is no convincing evidence of a better way about to be trod.

For more see:
http://www.christianpost.com/news/churches-more-like-fast-food-restaurants-one-pastor-thinks-so-50738/