The National Disability Insurance Scheme (NDIS) is “on track in terms of costs”, according to a position paper released by the Productivity Commission this week. The report further stated that:
if implemented well, it will substantially improve the well-being of people with disability and Australians more generally.
But the Commission’s paper also expressed some significant concerns at the speed the scheme is being rolled out, and that this could undermine its overall effectiveness. The report highlighted a number of areas that are proving challenging for those accessing the scheme. It noted that such barriers to access are, in fact, contributing to keeping the costs on track.
As a result, the government asked the Productivity Commission to undertake an independent review into the overall costs of the scheme, its value for money and long-term sustainability. The full report is due by September.
The current position paper goes to great lengths to acknowledge the size of the challenge in delivering the NDIS. It argues that the
scale, pace and nature of the changes it is driving are unprecedented in Australia.
When fully implemented, the scheme will involve the delivery of individualised support to 475,000 people at a cost of A$22 billion per year.
There is no doubt the NDIS is complex, but the Commission finds that there is “extraordinary” commitment to the success and sustainability of the scheme. It notes that making the scheme work is not simply the job of the National Disability Insurance Agency (NDIA), but also that of government, participants, families and carers, providers and the community.
Based on the data collected, the Commission finds NDIS costs are broadly on track with the modelling of the NDIA. A greater number of children are entering the scheme than expected, leading to some cost pressures, but the report notes the NDIA is putting initiatives in place to help deal with these challenges.
The report also finds benefits of the NDIS becoming apparent, with many, but not all, NDIS participants receiving more disability support than previously and having more choice and control.
Problems with the scheme
Many people who are dissatisfied with the scheme have reported they couldn’t find care providers to deliver their funded and approved plans. This kind of under-utilisation of services is a factor contributing to keeping costs on track. Such findings are in line with recent independent research into consumer experiences of the scheme.
Overall the report finds there is insufficient flexibility in the NDIA’s operational budget and that money could be spent more in a way that reflects the insurance principles of the scheme, such as greater amounts of funding being invested in prevention and early intervention services.
The process of care planning needs greater attention. Pressure on the NDIA to get numbers of people on to the scheme means that the quality of the care planning processes have been decreased in some cases. This has caused “confusion for many participants about planning processes” and has resulted in poor outcomes for them.
There is a significant challenge in relation to the disability care workforce. The Commission estimates that one in five new jobs created in Australia in the next few years will need to be in the disability care sector. The report notes that current approaches to generating greater numbers of workers and providers are insufficient.
A range of responses required to address these include a more targeted approach to skilled migration, better market management, and allowing formal and informal carers to provide paid care and better price monitoring and regulation.
The interface between the NDIS and other disability and mainstream services has also proved problematic. There is a lack of clarity in terms of where the responsibilities of different levels of government lie and who should be providing which services. Some people with a disability have lost access to supports they used to get as state government disability services close down.
Need for political will
The Commission describes the roll-out to the full scheme as “highly ambitious” and expresses concern it risks not being implemented as intended. Indeed the speed of the NDIS roll-out is described as having “put the scheme’s success and financial sustainability at risk”.
The report concludes that if the scheme is to achieve its objectives there needs to be a
better balance between participant intake, the quality of plans, participant outcomes, and financial sustainability.
The NDIS is taking a number of steps to deal with these issues but the Commission “is unable to form a judgement on whether such a refocus can be achieved while also meeting the roll-out timetable”.
What all of this means is that we will need to see some enormous political will to enable the scheme to be supported to reach its full potential. This will likely involve some slowing of the timetable for implementation and some difficult work to deal with a number of the areas that have been identified as problematic. Whether the government has an appetite to see this through remains to be seen.
If you have a blocked or runny nose, chances are you’ll reach for a tissue or hanky to clear the mucus by having a good blow.
But is there a right way to blow your nose? Could some ways make your cold worse? And could you actually do some damage?
The three most common reasons for extra mucus or snot are the common cold, sinusitis (infection or inflammation of the sinuses, the air-filled spaces inside the face bones) and hay fever. Each of these conditions cause the lining in the nose to swell up, and to produce extra mucus to flush away infection, irritants or allergens.
Both the swelling and extra mucus lead to nasal congestion. This is when the narrowed passages increase the effort of breathing through the nose. Clearing the mucus by blowing the nose should reduce this congestion somewhat.
At the beginning of colds and for most of the time with hay fever, there’s lots of runny mucus. Blowing the nose regularly prevents mucus building up and running down from the nostrils towards the upper lip, the all-too-familiar runny nose.
Later in colds and with sinusitis, nasal mucus can become thick, sticky and harder to clear.
Think of “snotty nosed kids”, in particular infants or toddlers who haven’t yet learnt to coordinate the mechanics of blowing their noses. They tend to repeatedly sniff thick mucus back into their nose or allow it to dribble down their upper lip.
Keeping this mucus (rather than blowing it out) is thought to contribute to a cycle of irritation that causes the snotty nose to persist for weeks or longer.
This may be due to the retained mucus acting as a good “home” for bacteria to grow in, as well as fatigue of the “hairs” (cilia) that cleanse the nose by moving along mucus and carrying with it irritants, inhaled debris and bacteria.
Thick retained mucus is also more likely to be transported to the throat rather than gravity working it from the nostrils, leading to throat irritation and possibly a cough. This is the mechanism behind the most common cause of prolonged cough after a viral infection or hay fever, known as the post-nasal drip cough.
So it makes sense to encourage people to blow their nose to remove unwanted mucus.
Rare risks if you blow too hard and too often
Although extremely rare, there are a few examples in the medical literature of people blowing so hard they generated pressures high enough to cause serious damage. In most of these cases people had underlying chronic sinusitis or an existing weakness in the structure they damaged after blowing too hard.
One study looked at the pressures generated when people with and without a range of nasal complaints blew their noses.
People with chronic sinusitis generated pressures significantly higher than people without a nasal complaint, up to 9,130 Pascals of pressure. They also found blowing by blocking both nostrils generated much higher pressures than blowing with one nostril open.
Another study comparing pressures from nose blowing, sneezing and coughing found pressures generated during blowing were about ten times higher than during the other two activities.
More worrying was their second finding – viscous fluid from the nose had found its way into the sinus cavities after vigorous nose blowing. The researchers said this could be a mechanism for sinus infection complicating some colds, with the introduction of nasal bacteria to the sinuses. But they did not produce evidence for this.
On balance it seems repeated and vigorous blowing of the nose may carry more risk than benefit, even though it seems to be a natural response to nasal congestion.
Can I take anything to stop the snot?
So looking to remove the need to blow so forcefully is probably a better option.
Decongestants contain ingredients like oxymetazoline and phenylephrine and come in tablets or sprays, and are often included in cold and flu tablets. They work by constricting (narrowing) dilated blood vessels in the inflamed lining of the nose, and decreasing the volume of mucus produced.
While decongestant sprays are effective, they are probably underused due to concerns about nasal congestion when you stop taking them after long-term use (rhinitis medicamentosa). But further studies have questioned this increased risk.
Antihistamines treat nasal congestion associated with hay fever, but may be less effective for treating cold symptoms.
Saline nose sprays have some evidence they work for acute and chronic rhinosinusitis (inflammation of the nasal lining and sinuses), and can reduce the need for medications. They are believed to clear mucus through increasing the effectiveness of the cilia as well as diluting thick and sticky mucus.
A related technique, known as nasal aspiration, is when you squirt liquid saline up the nose with a special medical device to flush out mucus and debris from the nose and sinuses. One study found it lowered the risk of developing acute otitis media (inflammation of the middle ear) and rhinosinusitis.
What’s the verdict?
If you have mucus in the nose, it is probably best to get it out, so blow gently or by clearing one nostril at a time. Use of appropriate treatments can lessen the need to blow, and the force required to clear your nose.
If you are repeatedly blowing your nose you probably have a nasal condition, like hay fever or sinusitis, which should be treated more comprehensively.
And if you see a snotty-nosed kid, please wipe away the mucus discharge for the benefit of all.
The statement “we have plenty of doctors in Australia” would probably not pass the pub test. Especially if the pub was in a regional city, a remote town or a less-than-leafy suburb. But it is true all the same – statistically at least.
And then there’s this question: if we are now so flush with medicos, why do we still need to import so many from overseas? To fill job vacancies, the Australian government granted 2,820 temporary work visas to overseas-trained doctors in 2014-15. In the same year, Australian medical schools graduated another 3,547.
This heroic level of doctor production and importation is right up there internationally. Among wealthy nations, Australia is vying for the top spot, with only Denmark and Ireland in the same league of doctor-production for population.
So why do we have too many doctors, but think we have too few?
Our approach to medical training
In a Medical Journal of Australia editorial published today, we examine the question of “work readiness” in our new medical graduates from arguably the most important perspective: what the community needs from future doctors.
To what extent is our medical training system producing doctors who will be providing the high quality, person centred, affordable health services we need, given we are an ageing population living with higher levels of chronic and complex health conditions?
There have been arguably three problems with the Australian approach to the medical workforce to date. First, we didn’t finish the job of production; second, we’ve allowed too much medical specialisation in major cities; and third, our models of health care and the ways we pay for it are out of step with where community needs are heading.
Back in the early 2000s, the biggest issue relating to the training of Australia’s medical workforce was a shortage of doctors in regional and remote areas. So, in addition to boosting medical student numbers overall, we set up rural clinical schools and regional medical schools, and increased admission of students who were already residents of rural areas.
While results of these policies have been positive in terms of graduate rural career intentions and rural destinations, the job was really only half done. What we didn’t do is reform the training that goes on after medical school.
That involves internships and training for one of 64 specialty fellowships, including general practice. Because of that, too many of our medical graduates are now piling up in capital city teaching hospitals, locked in a fierce competition for ever-more sub-specialised training jobs.
Meanwhile regional Australia remains hooked on a temporary fix of importing doctors from overseas. Hence the recently announced funding for 26 new regional training hubs. The aim is to “flip” the medical training model, so the main training is offered regionally with a city rotation as required.
2. Excessive specialisation
There’s no question we need a reasonable number of doctors who are experts in a narrow field. However, there’s now an imbalance between an inadequate number of medical generalists and excessive numbers of specialists in every major medical field.
Regional Australia in particular needs more generalists; that is rural generalist GPs, general surgeons, general physicians and the like.
3. Financing and models of care
Health expenditure is driven by three main factors: growth in population, providing more care for each patient and the increase in the proportion of older people with increased complex care needs.
Improvements in health-care technology means we can diagnose illness more accurately, less invasively and earlier, and we have more effective treatments.
However, in a system that pays on the basis of every service provided (regardless of need) there is also a risk of provider-induced demand. This can lead to inappropriate medical care, with examples in unwarranted eye, knee and back surgery, imaging, colonoscopy, and medication for depression and other conditions.
An undersupply of doctors is associated with lower rates of health-care use, whereas oversupply or mis-distribution can lead to higher rates of inappropriate care. Balancing the distribution of doctors according to need has important consequences for health-care costs.
Time for action
Make no mistake, Australia’s current health system is good by world standards. But the headwinds are building. The population is ageing, we’ve got more people with chronic and complex health-care needs, and the costs of new medicines and technologies continue to escalate.
Having injected a massive boost of doctors into a fee-paying healthcare system without regard to population need, workforce mix, geographic location, health-care models or financing reform, we have put the future at risk.
Let’s not let this bold experiment fail for want of follow-through. We need more urgency in providing the incentives and training opportunities to get our growing junior medical workforce into the specialties and areas that are underserved.
We have to stop allowing medical specialty training to be driven by the work rostering requirements of metropolitan hospitals. We must increase the number of specialist training positions based in regional centres.
And we especially need to expand the number of broadly-skilled rural generalists and get serious about efficient, team based, health-care models. This requires cooperation by all governments, medical schools, specialist colleges and the profession – and the time to act is now.
Treasurer Scott Morrison pulled a health-related rabbit out of his hat on budget night, announcing the government will “guarantee” the future of Medicare.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.