Don’t be fooled, the Medicare Guarantee Fund provides no real guarantee



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The Medicare Guarantee Fund appears to be no more than an accounting trick.
from shutterstock.com

Stephen Duckett, Grattan Institute

Treasurer Scott Morrison pulled a health-related rabbit out of his hat on budget night, announcing the government will “guarantee” the future of Medicare. The Conversation

It will do this by allocating revenue from the recently increased (from 2% to 2.5%) Medicare levy, after paying for the National Disability Insurance Scheme (NDIS), into a Medicare Guarantee Fund.

The government will then cover the shortfall to cover the costs of Medicare – defined in these budget announcements as a combination of expenditure from the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS). In Morrison’s words:

Proceeds from the Medicare levy will be paid into the fund. An additional contribution from income tax revenue will also be paid into the Medicare Guarantee Fund to make up the difference.

Based on the sketchy information so far available, this fund appears to be no more than an accounting trick. The size of the fund will be determined each year based on projected MBS and PBS expenditure. The balancing item, which is the extra proportion of non-NDIS revenue, will also be adjusted each year in line with those expenditure projections.

The guarantee part is that only the MBS and PBS expenditures can be paid from the fund, “by law”. This might sound good, but don’t be fooled. The Medicare Guarantee Fund is nothing more than a rebadging exercise: it changes the badge on a policy in the hope people might think it is a new policy.

It merely provides an additional line in the budget papers, supplementing information that was already there for MBS and PBS expenditure, albeit separately. And by defining Medicare as MBS and PBS expenditure, the government has seamlessly airbrushed public hospitals out of the picture.

What is Medicare?

Until budget night this week, most people would have thought of Medicare as the medical services and public hospital scheme, and probably still do.

When Medicare was introduced in 1984, it changed funding arrangements for medical services and public hospitals, removing or reducing financial barriers to access to these services. It did not touch PBS arrangements.

It may now be appropriate to add the PBS as a third component of Medicare, as it is about access to health care. But the PBS should be an addition to how Medicare is defined. It shouldn’t be used to airbrush public hospital access out of any Commonwealth definition of Medicare.

To put it more simply, the Medicare Guarantee Fund does not include the Commonwealth’s contribution to public hospital funding. But it does include the PBS, adopting a unique and idiosyncratic definition of Medicare.

The Medicare Guarantee Fund is being created using a partial statement of Medicare spending: if the public were to assume the Medicare Guarantee Fund is purely about a public commitment to Medicare, they would be misled.

So despite Morrison’s claims the fund will provide “transparency about what it really costs to run Medicare”, Medicare funding will actually be less transparent.

What does the fund guarantee?

The government probably hopes the Medicare Guarantee Fund will be its armour against a revised Mediscare campaign, like the one Labor ran before the 2016 election. The word “guarantee” linked with “Medicare” sounds good, costs nothing and does not bind the government in any way. But it may be enough to ward off the Mediscare vampires.

Mediscare resonated in 2016 because of the 2014 budget decisions. These were seen as a breach of trust as they were policies that had been explicitly ruled out in the previous election campaign.

The controversial 2014 budget proposals aimed to reduce Commonwealth expenditure by shifting costs onto consumers and onto states. One way of doing this was through co-payments that required patients to make an out-of-pocket payment when they see a doctor.

Another cost-shifting policy was the Medicare rebate freeze, which froze MBS rebates for visits to doctors at 2013 levels, despite inflation since then which has been tracking at around 2% a year. Since rebates are also paid to consumers, this was another example of a consumer cost shift, although the burden of this strategy probably fell on providers, particularly general practitioners.

Some of the 2014 changes (like the co-payment) required legislation to implement, while others (like the rebate freeze) could be implemented by administrative action without requiring parliamentary approval.

Importantly, none of the changes that required legislation were successful. The only changes in the 2014 budget that were eventually implemented were the ones that didn’t require legislation, such as the rebate freeze and draconian public hospital budget cuts. These tore up a previous agreement under which the Commonwealth matched cost increases in public hospitals.

Even these two measures have now been partially wound back – the hospital cuts before the 2016 election, and the rebate freeze in the 2017 budget.

What should a Medicare guarantee look like?

A Medicare guarantee worth its salt would be one that protects the public from the administrative assaults of the 2014 budget. This would involve enshrining in legislation the Commonwealth-state health care agreements – as well as the “partnership” payments, which are other Commonwealth grants to the states for health care – and introducing automatic indexation of Medicare rebates.

The Medicare Guarantee Fund as proposed in the 2017 budget does not do this. It provides no guarantee of policy stability, no guarantee of additional funding, and no guarantee that a future budget will not tear into the Medicare fabric in the way that characterised the 2014 debacle.

Stephen Duckett, Director, Health Program, Grattan Institute

This article was originally published on The Conversation. Read the original article.

Mental health funding in the 2017 budget is too little, unfair and lacks a coherent strategy



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Mental health remains chronically underfunded.
from shutterstock.com

Sebastian Rosenberg, University of Sydney

This week’s federal budget allocated A$115 million in new funding over four years. This is one of the smallest investments in the sector in recent years. The Conversation

For instance, the Council of Australian Governments (CoAG) added more than $5.5 billion to mental health spending in 2006. The 2011-12 federal budget provided $2.2 billion in new funding.

This compounds a situation in which, in 2014-15, mental health received around 5.25% of the overall health budget while representing 12% of the total burden of disease. There is no reason those figures should exactly match, but the gap is large and revealing.

They speak to the fact mental health remains chronically underfunded. Mental health’s share of overall health spending was 4.9% in 2004-05. Despite rhetoric to the contrary, funding has changed very little over the past decade.

We lack a coherent national strategy to tackle mental health. New services have been established this year, but access to them may well depend on where you live or who is looking after you. This is chance, not good planning.

Hospital-based services

The general focus of care when it comes to mental health remains hospital-based services. Inpatient – when admitted to hospital – and outpatient clinic care or in the emergency room represent the bulk of spending. (The Australian Institute of Health and Welfare includes hospital outpatient services under the heading “Community”, which makes definitive estimates of the proportion of funding impossible.)

Outside of primary care such as general practice, or Medicare-funded services (such as psychology services provided under a mental health care plan), mental health services in the community are hard to find.

An encouraging aspect of this year’s budget is the government’s recognition of this deficiency. The largest element of new mental health spending was a commitment to establish a pool of $80 million to fund so-called psychosocial services in the community.

As Treasurer Scott Morrison said in his budget speech, this money is 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.

Yet, the money is contingent on states and territories matching federal funds, meaning up to $160 million could be made available over the next four years if the states all chip in with their share of $80 million. But this commitment was made “noting that states and territories retain primary responsibility for CMH [community mental health] services”. Whether the states agree is another matter.

This new funding seems partly a response to the federal transfer of programs such as Partners in Recovery and Personal Helpers and Mentors to the National Disability Insurance Scheme (NDIS). Both these programs offered critical new capacity to community organisations to provide mental health services and better coordinate care.

Partners in Recovery was established in the 2011-12 budget with $550 million to be spent over five years. Personal Helpers and Mentors (along with other similar programs) was established in the same year with $270 million in funding over five years.

With these programs now (or soon to be) cordoned off to recipients of NDIS packages, the 2017 budget measure appears to be designed to offset their loss. However, not all states may choose to match the federal funds. And some may choose to do so but try to use new federal funds to reduce their own overall mental health spending.

States already vary in the types of services they offer. All this raises the prospect that people’s access to, and experience of, mental health care is likely to vary considerably depending on where they live. In a budget espousing fairness, this is a recipe for inequity.

Lack of coherent strategy

The budget does attempt to improve the uneven distribution of mental health professionals by providing $9 million over four years to enable psychology services to rural areas though telehealth. It’s well known mental health services in the bush are inadequate.

This investment seems sensible, but $9 million pales in comparison to spending on the Better Access Program, which I have calculated to be $15 million each week. This program provides Medicare subsidies for face-to-face mental health services under mental health care plans. While this program is available for those in rural areas, accessing it is more difficult than in cities.

This budget’s commitment to mental health shows a lack of an overarching strategy. Rather than offering a coherent approach to mental health planning, this budget continues Australia’s piecemeal, patchwork structure, where the system is driven mostly by who pays rather than what works or is needed.

The development of a national community mental health strategy would be most welcome now. This would demonstrate how the primary and tertiary mental health sectors will join up to provide the blend of clinical, psychological and social support necessary to finally enable people with a mental illness to live well in the community.

You could be forgiven for thinking that, albeit slowly, the well-known problems in mental health across Australia are being addressed. But the small pool of funding in this year’s budget says otherwise. And the lack of coherent strategy is a shame. You can’t complete a jigsaw puzzle if you keep adding new pieces.

Sebastian Rosenberg, Senior Lecturer, Brain and Mind Centre, University of Sydney

This article was originally published on The Conversation. Read the original article.

Labor to oppose Medicare levy for lower- and middle-income earners


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Bill Shorten arrives to deliver the budget reply speech.
Mick Tsikas/AAP

Michelle Grattan, University of Canberra

Opposition Leader Bill Shorten has said Labor will oppose the budget’s increase in the Medicare levy hitting taxpayers on incomes under A$87,000. The Conversation

And he has flagged a Labor government would reimpose the deficit levy on high-income earners, that automatically expires on June 30. “Labor will not support spending $19.4 billion on the wealthiest 2% of Australians,” he said in his budget reply on Thursday night.

Labor says that a combination of the pared back levy rise and the deficit levy would deliver an extra $4.5 billion over ten years “without putting the burden onto families earning modest incomes”.

The combination would mean that, under Labor’s proposal, those on incomes of more than $180,000 would pay a 49.5% marginal tax rate.

After the opposition hedged its position last week, Shorten has confirmed a Labor government would put an extra $22 billion into schools above the amount the government has pledged, going back to the original ALP plan.

In an extensive attack on key budget measures, Shorten said Labor will oppose the government’s cuts to universities, its proposed increase in student fees, and the change in the repayment threshold that “hits women, Indigenous Australians and low-income earnest the hardest”.

In power, it would reverse the government’s new cuts to TAFE.

Labor would also oppose the budget plan to give a tax break for people saving for their first home. Shorten said this was a “cruel hoax”, a joke and an insult, representing just $565 for each first home.

He said the 0.5% boost in the Medicare levy – imposed to fund the National Disability Insurance Scheme and to take effect from mid-2019 – would affect every Australian down to an income of $21,000.

It would mean a worker on $55,000 would pay $275 extra a year, while someone on $80,000 would face an extra $400.

“Labor cannot support making people on modest incomes give up even more of their pay packets,” he said. Labor would only support the levy rise for those in the top two tax brackets.

Shorten said the budget “fails the fairness test” and it “fails the generational test”.

It was a “budget of big government, higher tax and more debt” and “devoid of values altogether”.

He dismissed the government’s measures to protect Medicare, saying that Malcolm Turnbull “only discovers his heart when he feels fear in it”.

The opposition leader was at pains to counter the widespread observation in commentary that this was “a Labor budget”.

He confirmed Labor would not oppose the budget’s tax on big banks, which has sparked a furious reaction from the banking sector.

But it was worried that “the weakness of this government will turn $6 billion tax on the banks into a $6 billion charge on every Australian with a bank account or a mortgage”.

The banks knew they could run over the top of this weak prime minister, he said.

“He’s giving them a levy with one hand, a tax cut with the other and a free pass for bad behaviour. I’ll give them a royal commission.”

He said that “if the banks pass on a single dollar of this tax to Australian families then that should be the end of this treasurer, this prime minister and this government”.

Shorten said that since budget night Labor had identified $1 billion in measures it would not support, including the $170 million set aside for a marriage equality plebiscite to which the Senate has refused to agree.

Earlier, in Question Time, the opposition extracted from the government the fact that the cost of its ten-year corporate tax cut – the first part of which is already legislated – would be $65 billion over the upcoming decade, compared with nearly $50 billion over a decade when announced a year ago.

In his budget reply, Shorten said: “This is a recipe for fiscal recklessness on a grand scale. It is a threat to Australia’s triple A credit rating – and therefore a threat to every Australian mortgage holder”.

Labor’s plan to close tax loopholes that let big companies shuffle money internationally would deliver $5.4 billion over a decade.

Shorten announced that a Labor government would cap at $3,000 the amount people could deduct for the management of their tax affairs. Although affecting only one in 100 taxpayers, this would save $1.3 billion over the medium term.

Finance Minister Mathias Cormann called on Shorten to submit his speech to the Parliamentary Budget Office for costing.

“If Bill Shorten is serious he needs to come clean with the Australian people about how much bigger the deficit would be over the forward estimates period as a result of the announcements that he has made,” Cormann said.

He said Labor’s numbers did not add up and it would put the triple A credit rating at risk.

Social Services Minister Christian Porter said that Labor had not outlined enough to fund the NDIS.

https://www.podbean.com/media/player/55eic-6aa7da?from=yiiadmin

Michelle Grattan, Professorial Fellow, University of Canberra

This article was originally published on The Conversation. Read the original article.

Prescribing generic drugs will reduce patient confusion and medication errors



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If doctors prescribe generic drugs rather than their brand name equivalents, most times patients benefit.
from www.shutterstock.com

Matthew Grant, Monash University

In last night’s federal budget, Treasurer Scott Morrison announced an anticipated range of measures to encourage doctors to prescribe generic medicines rather than their more expensive brand name equivalents. So unless specified by the doctor, patients will receive a prescription with the generic medication name on it. The Conversation

This is part of A$1.8 billion in measures announced to reduce the drugs bill over five years. But beyond saving costs, the push towards generics may also reduce confusion among patients and medication errors.


“Are you taking aspirin at the moment?” I ask Iris, a pensioner in her 80s.

“No dear, I haven’t taken that for years,” she says, as she empties a large brown paper bag filled with medication boxes, new, old and empty.

I see a new bottle of aspirin emerge from the bag and ask if she is taking them.

“Oh yes, I always take my Astrix tablets.”

It’s not just elderly people who can be confused about which medication they’re taking. Drug names are long, complex and there are usually multiple brands for the same product.

For any medication, there are likely to be up to 15 different brands available. People are likely to use these brand names to describe the drug, like Iris did with her Astrix tablets.

In Australia in 2010 only 19.5% of scripts issued by GPs used the generic term for a drug, compared with 83% in the United Kingdom.

Encouraging doctors to prescribe generics goes beyond economic value. It has the potential to lead to a simplification of the language around medications, less influence on our purchasing decision by pharmaceutical marketing, and fewer medication errors by both doctors and consumers.

When we visit the GP, unless a specific reason exists, we should receive a script written with the generic term.

What is a generic term for a medication?

The generic term for a medication is the name of the active ingredient it contains. This is the ingredient that actually does the work of controlling your asthma or reducing your risk of heart disease.

There is only one generic name for each medication. But several different brands may be available. The brand name is usually the largest writing on the packet. Nurofen, for instance, is the brand name for the generic medication ibuprofen.

Generic medications are available for older drugs, and are commonly offered by your pharmacist as a cheaper alternative to the original branded medication. These drugs are tested to contain exactly the same active ingredients, so they produce the same effects.

However, there are a few rare exceptions, such as in some epilepsy medications, where drug levels may differ slightly between brands. So in such cases, doctors can choose to prescribe the branded version for its specific clinical benefits.


Explainer: how to generic medicines compare with brand leaders?


Which medicine name your doctor writes on you prescription – brand name or generic – can often be a lottery.

If your doctor writes a prescription for a brand name, your pharmacist may offer to substitute this for an equivalent generic drug. So, people often leave the pharmacy with a medication name or package that bears no resemblance to the prescription.

Potentially confusing for patients

The main problem with all these multiple names is the potential for confusion, especially for those most likely to use multiple medications – the elderly.

As a result, patients are at risk of not understanding which medications they are taking or why they are taking them. This often leads to doubling-up of a certain drug (taking two brands of the same medication), or forgetting to take them because the name on the package doesn’t match the script.

This problem of some patients’ poor medication literacy significantly affects doctors, nurses and pharmacists, who need to know which medications people are using. While our own GP may have your list of medications, often we visit multiple doctors who won’t have access to these list (different GPs while on holidays, emergency departments or specialists). If patients doesn’t know their medications, neither will doctors.

Many elderly patients are confused about the names of their medications.
from shutterstock.com

An advisory group for Australian pharmaceuticals, well aware of the dangers this confusion can cause, and as far back as 2005, promoted the use of prescribing and labelling with generic terms. The US Institute for Safe Medication Practices estimates that 25% of medication errors result from name confusion.

Why do doctors use brand names when prescribing?

In a busy clinic running half an hour behind, the generic name of a medication is often the last thing on the doctor’s mind. There are thousands of medications and even the most diligent doctor can’t remember them all.

Pharmaceutical companies have marketed brand name medication to both doctors and (in some countries) consumers, so they are far more memorable and palatable – for instance Viagra, rather than the generic term sildenafil.

But when doctors rely on using brand names in conversation and prescribing, this can cause confusion. Doctors using branded prescribing can lead to serious medication errors. This may be due not knowing the active ingredients in those medications, or mixing up brand names, which are becoming increasingly difficult to recognise when written in doctor’s handwriting.

So, to avoid confusion, medication errors and allowing for patient control over purchasing decisions, we recommend doctors use generic terms when prescribing unless a specific reason exists.

How does this affect me?

Everyone uses medications. The key issue here is autonomy. A script that contains the generic term for a medication allows that person to decide exactly what type of medication they wish to purchase, rather than that be influenced by what brand the doctor writes on the script.

When language excludes (for instance, by being complex or relying on jargon) or confuses, it restricts our autonomy. At present, the language of medications may have two, three or ten words for each drug, and the words we use are often influenced by pharmaceutical marketing and what a doctor prescribes.

The greatest effect of this budget announcement may be the chance to simplify this language to a singular generic drug term, to reduce confusion and allow us to be more involved with our medication decisions.

Matthew Grant, Research Fellow, Palliative Medicine Physician, Monash University

This article was originally published on The Conversation. Read the original article.

Budget 2017 sees Medicare rebate freeze slowly lifted and more funding for the NDIS: experts respond


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The future of the NDIS is seemingly secured in this federal budget.
from shutterstock.com

Stephen Duckett, Grattan Institute; Chris Del Mar; Elizabeth Savage, University of Technology Sydney; Helen Dickinson, UNSW, and Michael Woods, University of Technology Sydney

As expected, the government has announced a progressive lifting of the Medicare rebate freeze. Together with removing the bulk-billing incentive for diagnostic imaging and pathology services, as well as an increase in the PBS co-payment and related changes, this will cost a total of A$2.2 billion over the forward estimates. The Conversation

Other announcements include:

  • From July 1, 2019, an increase in the Medicare levy from 2% to 2.5% of taxable income, with the extra half a percent directed towards the NDIS
  • $1.2 billion for new and amended listings on the PBS, including more than $510 million for a new medicine for patients with chronic heart failure
  • a A$2.8 billion increase in hospitals funding over forward estimates
  • $115 million for mental health, including funding for rural telehealth psychological services, mental health research and suicide prevention
  • $1.4 billion for health research, including $65.9 million this year to help research into children’s cancer.

All up, these commitments equate to A$10 billion.

Medicare rebate freeze

Stephen Duckett, Health Program Director, Grattan Institute

As foreshadowed in pre-budget leaks, the government is slowly unthawing the Medicare rebate freeze, but at a snail’s pace. At a cost of A$1 billion over the forward estimates, indexation for Medicare items will be introduced in four stages, starting with bulk-billing incentives from July 1, 2017.

General practitioners and specialists will wait another year – until July 1, 2018 – for indexation to start up again for consultations, which make up the vast bulk of general practice revenue. Indexation for specialist and allied health consultations is slated to start from July 1, 2019.

Certain diagnostic imaging items (such as x-rays) will be the last cab off the rank. Indexation will start up again from July 1, 2020.

There is no mention of reintroducing indexation for pathology items. This may be due to the recognition that there is money to be saved in pathology.

Regardless of the reaction of medical lobby groups, it is too early to tell whether this glacially slow reintroduction of indexation will be enough to keep bulk-billing rates at their current levels. Practice costs and income expectations of staff have not increased dramatically over the freeze period as the Consumer Price Index has been moving slowly. But each additional day of a freeze means costs and revenues fall further out of alignment.

The jury will be out for a while on whether reintroduction of indexation is enough to restore the Coalition’s tarnished Medicare credentials with voters.

Certainly, the slow phase-in may attract cynicism, with a legitimate perception the government is doing the minimum necessary and at the slowest pace to ensure the issue is off the agenda before a 2019 election.

There is no sign in the budget that the government has sought any trade-offs from the medical profession in exchange for the reintroduction of indexation, so we will have to wait to put in place better foundations for primary care reform.

National Disability Insurance Scheme (NDIS)

Helen Dickinson, Associate Professor, Public Service Research Group, UNSW

Since its inception, a number of bitter political battles have been fought over how the National Disability Insurance Scheme should be funded. Many have been nervous the current Productivity Commission review of the costs of the scheme could lead to a scaling back of the NDIS before it is fully operational.

The NDIS operates under a complex funding arrangement split between federal, state and territory governments. Until now it has been unclear where the federal component of this commitment will come from, and a significant gap was emerging from the middle of 2019.

Today’s budget promises to fill this funding gap, in part through an increase by half a percentage point in the Medicare levy from 2% to 2.5% of taxable income. Of the revenue raised, one-fifth will be directed into the NDIS Savings Fund (a special account that will ensure federal cost commitments are met).

A commitment has also been made to provide funding to establish an independent NDIS quality and safeguards commission to oversee the delivery of quality and safe services for all NDIS participants.

This will have three core functions: regulation and registration of providers; complaints handling; and reviewing and reporting on restrictive practices. While such an agency will be welcomed by many, the devil will be in the detail as to whether it is possible to deliver this in practice.

Generic Medicines

Chris Del Mar, Professor of Public Health, Bond University

The government is set to save A$1.8 billion over five years by extending or increasing the price reduction for medicines listed on the Pharmaceutical Benefits Scheme (PBS).

This will be achieved in part by encouraging doctors to prescribe generic medicines that name the active ingredient (as in “90 octane petrol”) rather than the brand name (as in “BP” or “Shell”). This has the effect of pharmaceutical companies selling the drug that is cheapest.

It doesn’t work for drugs still under patent (which allows only pharmaceutical companies holding the patent to negotiate a price, compensating them for the drug development costs). But when drugs come off patent, any other pharmaceutical company can manufacture the generic drug for the best price.

Some doctors worry different brands might have different effects, but there are very few examples of patients being harmed by this. Australia’s Therapeutic Drugs Administration (TGA) makes sure drugs are manufactured to tight standards.

However, many patients know their medications by the brand name rather than the generic name. This same problem can happen right now (when patients are prescribed the same drug with two or more different names when they are prescribed by GPs, hospitals, or specialists).

Doctors are already alert to ensuring that different drugs names do not confuse patients – the danger is that they take the same drug twice, thinking they are different drugs.

Aged care

Michael Woods, Professor of Health Economics, University of Technology Sydney

The government has held the line on restraining growth in funding to residential aged care providers in this budget by implementing its pre-announced indexation freeze for the year, and a partial freeze in 2018-19.

The freeze was in response to concerns some providers were wrongly over-claiming payments under the Aged Care Funding Instrument (ACFI). The instrument determines the level of funding the government pays to providers to care for their residents.

The government has stopped publishing its annual target number of ACFI audits, so any proposed changes in compliance activity are now unknown.

The long-awaited consolidation of the Home Care Packages (which aim to help ageing Australians remain at home for as long as they need) and entry-level support through the Commonwealth Home Support Program has been put off for another two years, until at least 2020-21. This will be disappointing to consumers as a more seamless set of support services will improve their ability to remain in the community.

A welcome initiative is the additional A$8.3 million for more home-based palliative care services, although this extra support is budgeted to end in 2019-20.

Overall, the biggest unanswered issue facing the government in aged care is the need to develop an evidence-based and sustainable funding regime for residential care. To date we have seen short-term budget fixes and the commissioning of opaque rushed research reports.

The health minister needs to step back and establish a proper policy review process that undertakes sound research and consults widely. The review needs to establish a set of core funding principles and model options that address the varying incentives of residents, providers and taxpayers. It needs to adopt the one that transparently empowers consumers, provides market competition and results in long-term sustainability and certainty.

An inequitable budget

Elizabeth Savage, Professor of Health Economics, University of Technology Sydney

The budget has increased the Medicare levy (from 2.0% to 2.5%). It also has removed of the 2% budget repair levy, which benefits individuals with taxable incomes above A$180,000.

In 2014-15, only 3% of taxpayers had taxable incomes above $180,000. By contrast, the Medicare levy increase affects almost all taxpayers. This is a tax increase designed to generate revenue to fund the NDIS. The Medicare levy is essentially a flat tax, except for those at the lowest end of the distribution of taxable income.

Revenue could have been raised more equitably by increasing marginal income tax rates for higher earners (including making the budget repair levy permanent) or lowering upper tax thresholds.

What’s missing from the budget?

The 30% subsidy for private health insurance was introduced in 1999, and cost the budget A$2.1 billion in 2000-01. This cost has grown steadily and was estimated in the 2016-17 budget to be about A$7 billion for 2017-18. Despite high population coverage, consumers question whether private health insurance provides value for money.

There is abundant evidence the subsidy is an ineffective and costly policy, but it seems the politics keep reform of the subsidy in the too-hard basket.

From the budget speech and budget papers, it is not clear that there is any reform of the pricing of prostheses for private hospital patients. The Prostheses Listing Authority, the government regulator, sets minimum benefits for prostheses for private hospital inpatients.

The levels set are far higher than both prices in comparable overseas countries and those paid by public sector hospitals in Australia. Private hospitals are major beneficiaries when the regulated minimum benefits exceed the negotiated prices paid to suppliers.

Private health insurance premium increases are being driven by hospital benefits, of which 14.4% are for prostheses. In 2015, insurers paid out almost A$2 billion in hospital benefits for prostheses.

The previous health minister, Sussan Ley, raised prostheses reform as a priority, noting that insurers pay $26,000 more for a specific pacemaker for a private patient than a public patient ($43,000 compared with $17,000). It appears from early documentation that this problem has not been prioritised in this budget.

Stephen Duckett, Director, Health Program, Grattan Institute; Chris Del Mar, Professor of Public Health; Elizabeth Savage, Professor of Health Economics, University of Technology Sydney; Helen Dickinson, Associate Professor, Public Service Research Group, UNSW, and Michael Woods, Professor of Health Economics, University of Technology Sydney

This article was originally published on The Conversation. Read the original article.

Therapy for life-threatening eating disorders works, so why can’t people access it?



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Eating disorders are among the leading causes of hospitalisation for mental-health-related issues in Australia.
from shutterstock.com

Richard Newton, University of Melbourne

Eating disorders are complex mental illnesses that have one of the highest death rates of any psychiatric disorder. Among people with anorexia nervosa – who commonly deprive themselves of food due to an obsessive fear of gaining weight – this rate is more than five times greater than in the general population. The Conversation

All eating disorders are associated with significant, wide-ranging physical health complications such as starvation, cardiac arrest (sudden loss of heart function), kidney problems, food intolerance and fits. These are among the leading causes of hospitalisation for mental-health-related issues in Australia.

Because serious medical complications so frequently accompany eating disorders, they defy classification solely as mental illnesses. They should be viewed as complex health-care issues requiring urgent and multidisciplinary care.

Yet many health-care providers have not been provided with enough basic education and training to be able to recognise and respond appropriately to someone presenting with an eating disorder. So despite their severity, eating disorders often go unrecognised.

This leads to substantial economic costs for the Australian health system and devastating effects for sufferers, loved ones and the communities that surround them.

What are eating disorders?

Eating disorders have been around through recorded history. Even an ancient Egyptian tomb painting depicts a noble self-inducing vomiting.

There are several types of eating disorders. These include anorexia nervosa, bulimia nervosa and binge eating disorder. Collectively, these are characterised by abnormal eating behaviours, poor body image, overemphasis on weight and shape, and extreme weight-control behaviours.

In the case of anorexia, such behaviours lead to severe weight loss and often life-threatening complications. Vomiting, laxative abuse and excessive exercise can be features of both anorexia and bulimia, as can binging and purging.

Unlike the severe weight loss associated with anorexia, bulimia is characterised by the presence of binging and usually purging at a relatively normal weight. Binge eating disorder features frequent binging, in the absence of purging or other compensatory behaviours, which often leads to significant weight gain.

Eating disorders are also commonly accompanied by low self-esteem, guilt and disgust, along with depression, severe anxiety and suicide risk.

Who gets eating disorders?

There are psychological, environmental and biological (including genetic) risk factors for developing eating disorders. A genetic predisposition in combination with poor body image is one of the strongest predictors of disordered eating.

Poor body image has been reported in nearly half of Australian women and over one-third of Australian men. Disturbingly, the rate of body-image concerns is even greater in children and adolescents. A study of Australian children found up to 61% of girls and boys between the ages of eight and 11 are trying to control their weight.

Around 10% of the Australian population will experience an eating disorder in their lifetime, and the rate is increasing. For example, one study observed a two-fold increase in disordered eating between 1995 and 2005 in South Australia. And a more recent study in the same state observed a more than two-fold increase in extreme dieting and binge eating between 1998 and 2008.

While the reasons for this increase have not yet been fully explored, they may be related to increasing concerns about weight in the general Australian population.

Contrary to the long-held belief eating disorders are the domain of wealthy young females, the greatest increase has been observed in older people, males and those in lower socio-demographic groups.

This may be due, at least in part, to inadequate access to treatment, differences in people seeking treatment, or detection in under-represented groups, and stigma surrounding the development of a disorder commonly associated with a specific (different) group in the community.

How are they treated?

A number of evidence-based treatments are available for eating disorders. It is important to note that no single approach will be effective for all individuals.

People who are unable to access effective treatment early experience greater duration and severity of illness. They then need more complex, prolonged treatment.

Structured, psychological therapies are considered the cornerstone of treatment for eating disorders. For adolescents with anorexia, this takes the form of family-based therapy. This involves helping the whole family support the person with the disorder.

In adults with eating disorders, evidence shows a minimum of 20 sessions of cognitive behaviour therapy (CBT) – which challenges learnt ways of thinking – is necessary. In severe cases of anorexia, at least 40 CBT sessions that include a strong emphasis on restoring healthy eating attitudes and behaviours are required.

A multidisciplinary team is best equipped to address the complex nutritional, medical and psychological needs of someone with anorexia.

Increasing funding to improve outcomes

The total social and economic costs of eating disorders in Australia exceed A$69 billion per year. These costs can be reduced with early detection.

Most people with eating disorders go a long time before receiving adequate care. One study of over 10,000 adolescents found that, while nearly 90% of those with an eating disorder contacted a service provider for help, in only a minority (3-28%) of cases were the services specifically for their eating disorder.

Factors such as denial, shame, stigma and a lack of recognition of eating disorder symptoms by health-care professionals are likely contributors to this discrepancy.

Medicare provides Australians with funding for ten sessions with an allied mental-health professional (such as a psychologist or social worker). This is below the minimum treatment recommendation of 20 sessions for all eating disorders.

We should not accept a system that prevents people with a severe life-threatening mental illness from accessing a treatment that is available, effective and will save costs in the long term.

Federal Health Minister Greg Hunt recently requested the Medicare Benefits Schedule Review Taskforce investigate increasing Medicare coverage to treat people with an eating disorder. We urgently need early identification of eating disorders and the delivery of quality, targeted treatments at evidence-supported durations.

This article was co-authored by Tina Peckmezian, Principal Research Officer at The Butterfly Foundation.


If this article has raised concerns for you or anyone you know, call Lifeline 13 11 14, Suicide Call Back Service 1300 659 467 or Kids Helpline 1800 55 1800.

People with eating disorders or their families can get help at the Butterfly Foundation, 1800 33 4673, or The National Eating Disorders Collaboration.

Richard Newton, Associate Professor, University of Melbourne

This article was originally published on The Conversation. Read the original article.

Food as medicine: how what you eat shapes the health of your lungs



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Shifting your diet away from processed foods and towards fruits and vegetables can reduce symptoms of asthma.
from www.shutterstock.com

Lisa Wood, University of Newcastle

This article is part of a three-part package “food as medicine”, exploring how food prevents and cures disease. Read other articles in the series here. The Conversation


We all understand that eating too much of the wrong foods – those that are high in energy and low in nutrients, such as fast foods, processed foods and takeaways – causes weight gain and can lead to obesity. These foods are often high in saturated fat, refined carbohydrates (or sugars) and sodium, which increase the risk of developing diabetes, heart disease and some cancers.

But eating poorly has other, somewhat more surprising ramifications. Recently we have come to understand that unhealthy eating patterns can affect our lungs. Switching your diet to one rich in fruit and vegetables could help you breathe easier.

Healthy diets and healthy lungs

Most of the epidemiological evidence linking diet with lung function has focused on chronic obstructive pulmonary disease (COPD). Linked to smoking, COPD causes progressive lung deterioration and asthma.

Several large studies have observed people over time, and found that an unhealthy eating pattern (including refined grains, cured and red meats, desserts and French fries) increases the risk of lung function decline and COPD onset, compared to a healthy eating pattern (including fruit, vegetables, fish and wholegrains).

A recent study followed more than 40,000 men for 13 years, and found a high fruit and vegetable intake was associated with reduced risk of COPD. Current and ex-smokers eating five or more serves a day of fruit and vegetables were 30 to 40% less likely to develop COPD compared to those eating fewer than two serves per day.

A three year study in patients with existing COPD revealed those consuming a high fruit and vegetable diet had an improvement in lung function.

In asthma, there is evidence westernised diets, fast foods and processed foods increase the risk of asthma attacks, lung function decline, wheeze and breathlessness.

We have tested the effect of a high fruit and vegetable diet in asthma sufferers over three months. We found people consuming seven or more servings of fruit and vegetables per day had a reduced risk of asthma attacks, compared to people who consumed a low fruit and vegetable diet (fewer than three servings per day).

Another intervention study in asthma used a diet originally designed to reduce high blood pressure – the Dietary Approaches to Stop Hypertension (DASH) diet – for six months. One of the DASH dietary goals was to consume seven to 12 servings of fruit and vegetables, as well as two to four servings of low-fat/fat-free dairy products, and limiting daily fat and sodium intake. This led to improvements in asthma control and quality of life.

How do fruit and vegetables improve lung health?

People with respiratory diseases such as COPD and asthma typically suffer from inflamed airways. The airway tissue becomes swollen and hypersensitive, excess mucus is produced and the breathing tubes become damaged, sometimes irreversibly. The resulting narrowing of the airways makes it difficult for air to pass in and out of the lungs.

Failure to breathe freely can very quickly become life threatening. Restricted airflow can also have a debilitating effect on day-to-day activities, causing symptoms such as coughing, wheezing, breathlessness and chest tightness in people with asthma and COPD.

Fruit and vegetables are a rich source of several nutrients, in particular soluble fibre and antioxidants, that have been shown to reduce inflammation in the airways.

Dietary fibre reduces lung inflammation

Dietary fibre exists in soluble and insoluble forms. Soluble fibre is fermented by gut bacteria to produce short chain fatty acids. These can bind to specific receptors on the surface of immune cells, which suppress airway inflammation. We have shown a single dose of soluble fibre activates these receptors and reduces inflammation in human airways within just four hours.

Short chain fatty acids can also inhibit expression of the genes that cause airway inflammation, through a process known as epigenetic modification. So a high soluble-fibre intake has the potential to protect against airway inflammation through both activation of anti-inflammatory immune receptors, and inhibition of genes controlling inflammation.

Antioxidants are also anti-inflammatory

Antioxidants present in fruit and vegetables – such as vitamin C, carotenoids and flavonoids – are also beneficial, as they can protect against the damaging effects of free radicals, which are highly reactive molecules produced by activated inflammatory cells that can damage asthmatic airways. Many observational studies have linked antioxidants with lung health.

However, data from antioxidant supplementation trials in asthma are not convincing. Few studies show a beneficial effect, likely due to the use of individual nutrients. Multiple antioxidants exist together in fruit and vegetables, which have interdependent roles that are likely to be critical for their protective effects. So dietary modifications using whole fruit and vegetables is a better strategy.

Sometimes we can become overwhelmed by the nutrition messages in the media, which tell us to eat this and not eat that. Sometimes the advice seems contradictory and confusing. So here is a very simple and focused message for people with respiratory disease – eat more fruit and vegetables!

There’s really nothing to lose and everything to gain. As well as helping to maintain or achieve a healthy weight and reducing the risk of heart disease, diabetes and cancer, you will also be improving your lung health.


Further reading:

Food as medicine: why do we need to eat so many vegetables and what does a serve actually look like?

Food as Medicine: your brain really does want you to eat more veggies

Lisa Wood, Professor, University of Newcastle

This article was originally published on The Conversation. Read the original article.

Food as medicine: your brain really does want you to eat more veggies



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Diet reduces risk of depression through actions on bacteria in the gut, the immune system and the brain.
from www.shutterstock.com

Felice Jacka, Deakin University

This article is part of a three-part package “food as medicine”, exploring how food prevents and cures disease. Read other articles in the series here. The Conversation


As well as our physical health, the quality of our diet matters for our mental and brain health. Observational studies across countries, cultures and age groups show that better-quality diets – those high in vegetables, fruits, other plant foods (such as nuts and legumes), as well as good-quality proteins (such as fish and lean meat) – are consistently associated with reduced depression.

Unhealthy dietary patterns – higher in processed meat, refined grains, sweets and snack foods – are associated with increased depression and often anxiety.

Importantly, these relationships are independent of one another. Lack of nutritious food seems to be a problem even when junk food intake is low, while junk and processed foods seem to be problematic even in those who also eat vegetables, legumes and other nutrient-dense foods. We’ve documented these relationships in adolescents, adults and older adults.

Diet has an impact early in life

The diet-mental health relationship is evident right at the start of life. A study of more than 20,000 mothers and their children showed the children of mothers who ate an unhealthier diet during pregnancy had a higher level of behaviours linked to later mental disorders.

We also saw the children’s diets during the first years of life were associated with these behaviours. This suggests mothers’ diets during pregnancy and early life are both important in influencing the risk for mental health problems in children as they grow.

This is consistent with what we see in animal experiments. Unhealthy diets fed to pregnant animals results in many changes to the brain and behaviour in offspring. This is very important to understand if we want to think about preventing mental disorders in the first place.

Teasing out the cause from the correlation

It’s important to note that, at this stage, most of the existing data in this field come from observational studies, where it is difficult to tease apart cause and effect. Of course, the possibility that mental ill health promoting a change in diet explains the associations, rather than the other way around, is an important one to consider.

What comes first, the junk food or the depression?
from shutterstock.com

Many studies have investigated this and largely ruled it out as the explanation for the associations we see between diet quality and depression. In fact, we published a study suggesting that a past experience of depression was associated with better diets over time.

But the relatively young field of nutritional psychiatry is still lacking data from intervention studies (where study participants are given an intervention that aims to improve their diet in an attempt to affect their mental health). These sorts of studies are important in determining causality and for changing clinical practice.

Our recent trial was the first intervention study to examine the common question of whether diet will improve depression.

We recruited adults with major depressive disorder and randomly assigned them to receive either social support (which is known to be helpful for people with depression), or support from a clinical dietitian, over a three-month period.

The dietary group received information and assistance to improve the quality of their current diets. The focus was on increasing the consumption of vegetables, fruits, wholegrains, legumes, fish, lean red meats, olive oil and nuts, while reducing their consumption of unhealthy “extra” foods, such as sweets, refined cereals, fried food, fast food, processed meats and sugary drinks.

The results of the study showed that participants in the dietary intervention group had a much greater reduction in their depressive symptoms over the three months, compared to those in the social support group.

At the end of the trial, 32% of those in the dietary support group, compared to 8% of those in the social support group, met criteria for remission of major depression.

These results were not explained by changes in physical activity or body weight, but were closely related to the extent of dietary change. Those who adhered more closely to the dietary program experienced the greatest benefit to their depression symptoms.

While this study now needs to be replicated, it provides preliminary evidence that dietary improvement may be a useful strategy for treating depression.

Depression is a whole-body disorder

It’s important to understand researchers now believe depression is not just a brain disorder, but rather a whole-body disorder, with chronic inflammation being an important risk factor. This inflammation is the result of many environmental stressors common in our lives: poor diet, lack of exercise, smoking, overweight and obesity, lack of sleep, lack of vitamin D, as well as stress.

Many of these factors influence gut microbiota (the bacteria and other microorganisms that live in your bowel, also referred to as your “microbiome”), which in turn influence the immune system and – we believe – mood and behaviour.

In fact, gut microbiota affect more than the immune system. New evidence in this field suggests they are important to almost every aspect of health including our metabolism and body weight, and brain function and health. Each of these factors is relevant to depression risk, reinforcing the idea of depression as a whole-body disorder.

What is the human microbiome?

If we do not consume enough nutrient-dense foods such as fruits, vegetables, fish and lean meats, this can lead to insufficiencies in nutrients, antioxidants and fibre. This has a detrimental impact on our immune system, gut microbiota and other aspects of physical and mental health.

Gut microbiota are particularly reliant on an adequate intake of dietary fibre, while the health of the gut may be compromised by added sugars, fats, emulsifiers and artificial sugars found in processed foods.

A diet high in added fats and refined sugars also has a potent negative impact on brain proteins that we know are important in depression: proteins called neurotrophins. These protect the brain against oxidative stress and promote the growth of new brain cells in our hippocampus (a part of the brain critical for learning and memory, and important to mental health). In older adults we have shown that diet quality is related to the size of the hippocampus.

Now we know diet is important to mental and brain health as well as physical health, we need to make healthy eating the easiest, cheapest and most socially acceptable option for people, no matter where they live.


Further reading:

Food as medicine: why do we need to eat so many vegetables and what does a serve actually look like?

Felice Jacka, Principal Research Fellow, Deakin University

This article was originally published on The Conversation. Read the original article.

Food as medicine: why do we need to eat so many vegetables and what does a serve actually look like?


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Why do we need so many serves of vegetables in a day?
Unsplash/Jonathan Pielmayer, CC BY-SA

Genevieve James-Martin, CSIRO; Gemma Williams, CSIRO, and Malcolm Riley, CSIRO

This is the first article in a three-part package “food as medicine”, exploring how food prevents and cures disease. The Conversation


Most Australian adults would know they’re meant to eat two or more serves of fruit and five or more serves of vegetables every day. Whether or not they get there is another question.

A recent national survey reported 45% of Australian women and 56% of Australian men didn’t eat enough fruit. And 90% of women and 96% of men didn’t eat enough vegetables. This figure is worse than for the preceding ten years.

Men had on average 1.6 serves of fruit and 2.3 serves of vegetables per day, and women had 1.8 serves of fruit and 2.5 serves of vegetables. A serve of fresh fruit is a medium piece (about 150 grams) and a serve of vegetables is half a cup of cooked vegetables or about a cup of salad.


The Conversation/Australian Dietary Guidelines, 2013, CC BY-ND

Why do we need so many veggies?

A high intake of fruit and vegetables lowers the risk of type 2 diabetes, heart disease, stroke and some cancers. These chronic diseases are unfortunately common – it’s been estimated A$269 million could have been saved in 2008 if everyone in Australia met fruit and vegetable recommendations.

The recommendation to include plenty of vegetables and fruit in our diet is based on a large body of evidence showing the risk of a range of health conditions is reduced as we eat more fruit and vegetables. The specific targets of two serves for fruit and five to six serves for vegetables are largely based on nutrient requirements for healthy people and what diets usually look like for the average Australian.

So to set these guidelines, certain assumptions are made about dietary practices, such as breakfast being based around cereal/grain and dairy foods, and main meals being comprised of meat and vegetables, usually with a side of something starchy like rice, pasta or the humble potato – an Australian staple.

Does this mean it’s the only pattern to meet all the nutrient requirements? No. Could an adult be equally healthy if they ate three serves of fruit and four serves of vegetables? Yes, probably.

Some recent research even suggests our current targets don’t go far enough. It estimates an optimal intake for reducing our risk of heart disease and early death to be around ten serves of fruit and vegetables a day. Whether we are aiming for two and five, or ten serves, is somewhat academic – the clear message is most of us need to increase our fruit and vegetable intake.

Aussies eat more potatoes than any other veggie.
Agence Producteurs Locaux Damien Kühn/Unsplash, CC BY

Why is two and five such a hard ask?

The populations of most Western countries report eating far less fruit and vegetables than they’re supposed to. So what’s making it so hard for us to get to two and five?

Diets higher in fat, sugar and grains are generally more affordable than the recommended healthy diets high in fruit and veg. In fact, for Australians on low incomes, a healthy food basket for a fortnight would cost 28 to 34% of their income, up to twice the national average for food expenditure.

As a result, people with limited access to food for financial reasons often choose foods with high energy content (because they are filling) over those with high nutritional value but low energy content like fruit and vegetables. These high-energy foods are also easy to over-consume and this may be a contributing factor to weight gain. People who are poorer generally have a diet poorer in quality but not lower in energy content, which contributes to a higher rate of obesity, particularly in women.

Fresh fruit and vegetables cost more to purchase on a dollars per kilojoule basis, and also perish more quickly than processed foods. They take more time and skill to prepare and, after all of that effort, if they don’t get eaten for reasons of personal preference, they go to waste. For many it may not stack up financially to fill the fridge with fruit and vegetables. Under these circumstances, pre-prepared or fast food, which the family is sure to eat without complaint or waste, is all too convenient.

How we can increase veggie intake

The home and school environments are two key influencers of children’s food preferences and intakes. Parents are the “food gatekeepers” and role models particularly for younger children. Where there is parental encouragement, role modelling and family rules, there is an increased fruit and vegetable intake.

Dietary behaviours and food choices often start in childhood and continue through adolescence to adulthood. So encouraging fruit and vegetable intake in schools by mechanisms such as “fruit snack times” may be a good investment.

Policy approaches include subsidies on healthy foods. Other examples include levying a tax on foods of low nutritional value, improved food labelling, and stricter controls on the marketing of unhealthy foods. In Australia debate continues around a tax on sugar-sweetened beverages, which could be used to subsidise healthy foods such as fruit and vegetables.

Research has found the more variety in fruit and vegetables available, the more we’ll consume. Those who meet the vegetable recommendation are more likely to report having at least three vegetable varieties at their evening meal. So increasing the number of different vegetables at the main meal is one simple strategy to increase intake.

This could be made a journey of discovery by adding one new vegetable to the household food supply each week. Buying “in season” fruit and vegetables and supplementing fresh varieties with frozen and canned options can bring down the total cost. Then it’s a matter of exploring simple, quick and tasty ways to prepare them so they become preferred foods for the family.

Genevieve James-Martin, Research Dietitian, CSIRO; Gemma Williams, Research Dietitian, CSIRO, and Malcolm Riley, Nutrition Epidemiologist, CSIRO

This article was originally published on The Conversation. Read the original article.