Budget 2019 boosts aged care and mental health, and modernises Medicare: health experts respond



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The budget provides some short-term boosts for aged care and mental health but little opportunity for much-needed structural reform.
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Stephen Duckett, Grattan Institute; Hal Swerissen, Grattan Institute; Ian Hickie, University of Sydney; Lesley Russell, University of Sydney; Peter Sivey, RMIT University, and Philip Clarke, University of Melbourne

This year’s budget includes $448.5 to modernise Australia’s Medicare system, by encouraging people with diabetes to sign up to a GP clinic for their care. The clinic will receive a lump sum payment to care for the person over time, rather than a fee each time they see their GP.

The indexation freeze on all GP services on the Medicare Benefits Schedule (MBS) will lift from July 1, 2019, at a cost of $187.2 million. The freeze will be lifted on various X-ray and ultrasound MBS rebates from July 1, 2020.




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The budget announces $461 million for youth mental health, including 30 new headspace centres, some of which will be in regional areas. But it does little to address the underlying structural reforms that make it difficult for Australians to access quality and timely mental health care.

In aged care, the government will fund 10,000 home care packages, which have been previously announced, at a cost of $282 million over five years, and will allocate $84 million for carer respite. But long wait times for home care packages remain.

Other announcements include:

  • $62.2 million over five years to train new rural GPs
  • $309 million for diagnostic imaging services, including 23 new MRI licences
  • $331 million over five years for new pharmaceuticals, including high-cost cancer treatments
  • $107.8 million over seven years for hospitals and facilities including Redland Hospital, Bowen Hospital, Bass Coast Health and Ronald McDonald House
  • $70.8 million over seven years for regional cancer diagnosis, treatment and therapy centres
  • $114.5 million from 2020-21 to trial eight mental health facilities for adults
  • $43.9 million for mental health services for expectant and new parents
  • $35.7 million over five years for increased dementia and veterans’ home care supplements
  • $320 million this year as a one-off increase to the basic subsidy for residential aged-care recipients.

Here’s what our health policy experts thought of tonight’s budget announcements.


A hesitant step forward for Medicare

Stephen Duckett, Director, Health Program, Grattan Institute

Medicare funding is slowly creeping into the 21st century. The 19th-century model of individual fees for individual services – suitable for an era when medicine was essentially dealing with episodic conditions – is being supplemented with a new fee to better manage the care of people with diabetes.

The budget announcement, as part of the Strengthening primary care package, is for a new annual payment for each person with diabetes who signs up with a specific GP. Funding is provided for about 100,000 people to sign up – about 10% of all people with diabetes in Australia.

The new item number is consistent with the recent MBS review Report on General Practice, which recommended a move toward voluntary enrolment.

The precise details of the new fee – including the annual amount and any descriptors – have not yet been released. But it should encourage practices to move towards a more prevention-oriented approach to chronic disease management, including using practice nurses to call patients to check up on their condition, and using remote monitoring technology.

The budget announcement contained no evaluation strategy for the initiative. The government should produce such a strategy soon.


Support for aged and disability care

Hal Swerissen, Emeritus Professor, La Trobe University, and Fellow, Health Program, Grattan Institute

The budget has short-term measures to address major issues in aged care and disability while we wait for the royal commissions to fix the long-term problems.

The National Disability Insurance Agency (NDIA) is struggling with the huge task of putting the National Disability Insurance Scheme (NDIS) in place.

There has been a major under-spend on the on the scheme. Price caps for services such as therapy and personal care are too low and nearly one-third of services are operating at a loss. The under-spend would have been more if there hadn’t been a last-minute budget decision to significantly increase service caps, at a cost of $850 million.

$528 million dollars has also been announced for a royal commission to look at violence, neglect and abuse of people with disabilities – the most expensive royal commission to date.




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There is more funding for aged care. Currently, 130,000 older people are waiting for home care packages – often for a year or more. Nearly half of residential care services are losing money and there are major concerns about quality of care.

The short-term fix is to give residential care $320 million to try to prevent services going under. The budget includes 10,000 previously announced home care packages, at a cost of $282 million, but that still leaves more than 100,000 people waiting.

There’s still a massive shortfall in home care places.
eggeegg/Shutterstock

Little for prevention, Indigenous health and to address disparities

Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy, University of Sydney

Prevention

Preventable diseases and conditions are a key factor in health inequalities and rising health-care costs. The two issues looming large are obesity and its consequences, and the health impacts of climate change.

There is $5.5 million for 2018-19 and 2019-20 for mental health services in areas affected by natural disasters, and $1.1 million over two years for the Health Star rating system – otherwise nothing for primary prevention.

Indigenous health

The Treasurer did not mention Closing the Gap in his budget speech, and there is little in the budget for Indigenous health.

Just $5 million over four years is provided in the budget for suicide-prevention initiatives. And the Lowitja Institute receives $10 million for health and medical research.




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Some announcements in March contribute a little more:

Inequalities and disparities

Disadvantaged rural and remote communities will (ultimately) benefit from efforts to boost National Rural Generalist Training Pathway, with $62.2 million provided over four years. This was a 2016 election commitment.

The announcement of $200 million over three years to index Medicare payments for ultrasound and diagnostic radiology services (beginning from July 1, 2020) came with claims this will help reduce out-of-pocket costs. But given that these payments have not been indexed in 20 years, will the money go to providers or patients?

Hospitals and private health insurance

Peter Sivey, Associate Professor, School of Economics, Finance and Marketing, RMIT University

There are no major changes to public hospital funding arrangements in this year’s budget.

It’s business as usual for hospital funding, aside from funding injections for a handful of hospital sites.
By VILevi

Funding for public hospitals is predicted to increase at between 3.7% and 5.6% over the forward estimates. However, these figures are contingent on the new COAG agreement on health funding between the Commonwealth and states, which is due to be finalised before the end of 2019.

The states will be hoping to wring some more dollars from the federal government given their soaring public hospital admissions and pressure on waiting times.

There is no change to the government’s private health insurance policy which has just come into force.




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Government spending on the private health insurance rebate is projected to increase more slowly than premiums at between 1.8% and 3.2% because of indexation arrangements which are gradually reducing the rebate over time.


Smaller targets for mental health

Ian Hickie, Co-Director, Brain and Mind Institute, University of Sydney

Numerous reports and accounts from within the community have noted the flaws in Australia’s mental health system: poor access to quality services, the uneven roll-out of the NDIS, and the lack of accountability for reforming the system.

The next federal government faces major structural challenges in mental health and suicide prevention.

Not surprisingly, this pre-election budget does not directly address these issues. Instead, it focuses on less challenging but worthy targets such as:

  • continued support for expansion of headspace services for young people ($263m over the next seven years) and additional support for early psychosis services ($110m over four years)
  • support for workplace-based mental health programs ($15m)
  • support for new residential care centres for eating disorders ($63m).

A more challenging experiment is the $114.5 committed to eight new walk-in community mental health centres, recognising that access to coordinated, high-quality care that delivers better outcomes remains a national challenge.

Despite the commitment of health minister Greg Hunt to enhanced mental health investments, the total increased spend on these initiatives ($736.6m) is dwarfed by the big new expenditures in Medicare ($6b), improved access to medicines ($40b), public hospitals ($5b) and aged care ($7b).

It will be interesting to see whether mental health reform now receives greater attention during the election campaign. At this stage, neither of the major parties has made it clear that it is ready to deal directly with the complex challenges in mental health and suicide prevention that are unresolved.


New funding for research, but who decides the priorities?

Philip Clarke, Professor of Health Economics, University of Melbourne

The budget contains several funding announcements for research.

The government will establish a Health and Medical Research Office, to help allocate money from the Medical Research Future Fund (MRFF). This will be needed, as the budget papers commit to a further $931 million from the MRFF for:

  • Clinical trials for rare cancers and rare diseases
  • Emerging priorities and consumer-driven research
  • Global health research to tackle antimicrobial resistance and drug-resistant tuberculosis.
The budget includes funding for consumer-driven research and drug-resistant tuberculosis.
i viewfinder/Shutterstock

In addition, the budget includes:

  • $70 million for research into type 1 diabetes
  • a large investment for genomics (although that is a re-announcement of $500 million promised in last year’s budget)
  • a series of infrastructure grants to individual universities and institutions, such as $10 million to establish the Curtin University Dementia Centre of Excellence.



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The government appears to be moving away from allocating medical research funding through existing funding bodies, such as the National Health and Medical Research Council (NHMRC), towards allocating research funds to specific disease areas, and even to individual institutions.

This is a much more direct approach to research funding, but it raises a few important questions. On what basis are these funding decisions being made? And why are some diseases considered priorities to receive funding? There is very little detail to answer these questions.

Australia’s allocation of research funding through the MRFF is diverging from long-held traditions in other countries, such as the United Kingdom, which apply the “Haldane principle”. This involves researchers deciding where research funding is spent, rather than politicians.

* This article has been updated since publication to clarify the 10,000 home care packages have been previously announced.The Conversation

Stephen Duckett, Director, Health Program, Grattan Institute; Hal Swerissen, Emeritus Professor, La Trobe University, and Fellow, Health Program, Grattan Institute; Ian Hickie, Professor of Psychiatry, University of Sydney; Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy, University of Sydney; Peter Sivey, Associate Professor, School of Economics, Finance and Marketing, RMIT University, and Philip Clarke, Professor of Health Economics, University of Melbourne

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

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Mood and personality disorders are often misconceived: here’s what you need to know


Kathryn Fletcher, Swinburne University of Technology and Kristi-Ann Villagonzalo, Swinburne University of Technology

With each new version of the widely-used manual of mental disorders, the number of mental health conditions increases. The latest version (DSM-5) lists around 300 disorders. To complicate things, many share common features, such as depression and anxiety.

The manual is a useful guide for doctors and researchers, but making a diagnosis is not a precise science. So if the “experts” are still debating what’s what when it comes to categorising disorders, it’s not surprising misconceptions abound in the community about certain mental health conditions.

We learn about mental health conditions in a number of ways. Either we know someone who has experienced it, we’ve experienced it ourselves, read about it or seen something on TV. Movies and TV series commonly portray people with mental illness as dangerous, scary and unpredictable. The most popular (mis)representations are of characters with multiple personalities, personality disorders, schizophrenia and bipolar disorder.




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While the media is an important source of information about mental illness, it can misinform the public if reported inaccurately, promoting stigma and perpetuating myths. And research shows negative images of mental illness in the media (fictional and non-fictional) results in negative and inaccurate beliefs about mental illness.

Dissociative identity disorder

“Multiple personality disorder” or “split personality disorder” are colloquial terms for dissociative identity disorder. Despite being colloquially named a personality disorder, it’s actually a dissociative disorder.

A personality disorder is a long-term way of thinking, feeling and behaving that deviates from the expectations of culture. Whereas in dissociative identity disorder, at least two alternate personalities (alters) routinely take control of the individual’s behaviour. The individual is usually unable to remember what happened when an alter takes over: there are noticeble gaps in their memory, which can be extremely distressing.




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The popular TV series “The United States of Tara” actually does a pretty good job of portraying dissociative identity disorder. The main character has a series of alters and experiences recurrent gaps in her memory.

While it used to be considered rare, dissociative identity disorder is estimated to affect 1% of the general population, and is typically related to early trauma (such as childhood abuse). People commonly confuse dissociative identity disorder with schizophrenia. Unlike schizophrenia, the individual is not imagining external voices or experiencing visual hallucinations: one personality literally “checks out” and another appears in their place.

Borderline personality disorder

Borderline personality disorder is often misconstrued. People with this condition are often portrayed as manipulative, destructive and violent. In reality, these behaviours are driven by emotional pain: the person has never learned to ask effectively for what they need or want.

It is also often assumed “borderline” means the person almost has a personality disorder. The term “borderline” here creates some confusion. First introduced in the United States in 1938, the term was used by psychiatrists to describe patients who were thought to be on the “border” between diagnoses (mostly psychosis and neurosis). The term “borderline” has stuck in the diagnosis, but there is now a much better understanding of the causes, symptoms and treatment.




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Those with borderline personality disorder have difficulties regulating their emotions. This contributes to angry outbursts, anxiety and depression, and relationships fraught with difficulties. It’s also commonly associated with trauma (such as childhood abuse or neglect).

Many actions of a person with borderline personality disorder (such as self-harm and overdose) are done out of desperation in an attempt to manage difficult and intense emotions.




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Bipolar disorder

While borderline personality disorder and bipolar disorder can look similar (mood problems, impulsive behaviour and suicidal thinking), there are several key differences.

Bipolar disorder is characterised by extreme mood swings – from severe lows (depression) to periods of high activity, energy and euphoria. The different mood states can seem like a personality change, but a return to the “usual self” occurs once mood stabilises.

While depression is part of borderline personality disorder and bipolar disorder, those with bipolar disorder experience significant “up” mood swings. This is known as mania in bipolar I disorder and hypomania (less intense mania) in bipolar II disorder.




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Bipolar mood episodes last longer (four days or longer for “ups” and two weeks or longer for “downs”), with periods of wellness in between, and are less likely to be triggered by external events. And bipolar disorder is more likely to run in families, disrupt sleep patterns, and psychotic symptoms (delusions, hallucinations) can occur during mood episodes.

We all have ups and downs, but bipolar disorder is much more than that with extreme, recurrent mood episodes that are not only distressing, but have a significant long-term impact on key areas of a persons’s life. Positively, with the right treatment, good quality of life is entirely possible despite ongoing symptoms.

Schizophrenia

Schizophrenia, meaning “split mind” in Greek, is often confused with dissociative identity disorder. However, the “split” refers not to multiple personalities, but to a “split” from reality. People with schizophrenia may find it difficult to discern whether their perceptions, thoughts, and emotions are based in reality or not.

Hearing voices (auditory hallucinations) is a common symptom, along with seeing, smelling, feeling, or tasting things others can’t. Unusual beliefs (delusions), including some that cannot possibly be true (such as a belief that one has special powers) are also common. So too is disordered thinking, where the person jumps from one topic to another at random, or makes strange associations to things that don’t make sense. They may also exhibit bizarre behaviour including socially inappropriate outbursts or wearing odd clothing that is inappropriate to the circumstances.

Other symptoms of schizophrenia look a lot like depression, such as an inability to experience pleasure, social withdrawal and low motivation. Depressive symptoms are also present in schizophrenia, but are slightly different in that emotion is diminished altogether, rather than a depressed mood per se.




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Either mad and bad or Jekyll and Hyde: media portrayals of schizophrenia


Mental health conditions don’t come in neat packages

Unlike physical conditions, we don’t have a biological test that can magically tell us what mental condition we’re dealing with. Mental health practitioners are carefully trained to observe symptom patterns: the right diagnosis guides the appropriate treatment.

For example, first-line treatment of schizophrenia and bipolar disorder often focuses on medication. While dissociative identity disorder and borderline personality disorders are treated primarily with psychological therapy.

The ConversationMental health conditions are serious – whether disorders of personality, mood or somewhere in between. Improved understanding and balanced representation of these conditions is needed to shift stigmas and misconceptions in the community.

Kathryn Fletcher, Postdoctoral Research Fellow, Swinburne University of Technology and Kristi-Ann Villagonzalo, Postdoctoral Research Fellow, Swinburne University of Technology

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.