Health care costs more and more - where are we going?

[Tannin]

In another thread, there was a great long debate about health care funding, which generated much heat but little light. At one point we threatened to leave the immediate issues of party politics aside and move on to the very real and pressing reasons behind the controversy, but alas, that was derailed by more pages of pretty arguing from the usual suspects. So I'll try again here with a more-or-less repeat of my lost and buried post......



The bottom line reality is that federal funding for health care has consistently increased year on year by about double the rate of inflation. That's a very significant real-terms increase, and it's been more-or-less steady for better than ten years now. Howard, Rudd, Gillard, it doesn't matter - whoever has been in charge, from whichever party, the actual Commonwealth Government heathcare spend has gone up and up and up.
Reasons for this include:

• an ageing population (a factor, though not quite as big a factor as some people like to pretend)
  
• our out-of-control population growth (in health care terms, babies are very expensive, and young children also cost more than adults - only elderly people cost more still)
  
• expensive restrictive work practices by heath care professionals (doctors make very damn sure that they are always in short supply 'cause that helps them charge more)
  
• poorly-designed heath insurance schemes which do practically nothing to encourage healthy life choices which can massively reduce heath care costs
  
• the craven, cowardly stupidity of governments of both flavours which always cave in to the bad-health industries lobby and never, ever do anything to (for example) roll back junk food consumption or reduce the deadly practice of sodium and sucrose loading of nearly all packaged foods
  
• most of all, the ceaseless invention of new (and ever more expensive!) ways to treat disease, ways which Joe Public (quite understandably) demands by used right now!
  

Heathcare budgets have been a political minefield for more than 20 years now, and they are only going to get worse.

(PS: I don't know what the trend is in the typical state government healthcare spend. My guess is that the pressure there is also to spend more and more, but most state governments simply don't have any spare money as their revenue options are very limited, so possibly they have not increased their health budgets as they just don't have any money. But maybe they have, on average, managed to find a bit even so. I'd be interested to see figures if anybody has them.)

Topic open to all but I'd be particularly interested to hear your views, Stui, along with those of others who work in the industry - Morrigu is one, and I think WPT is another, but there may be more.

[stui magpie]

Good summary, I think you've hit a lot of the high points already.

Disclaimer up front, I'm not a clinician.

There are a number of things that all play a part in influencing the increased cost of health care, but no single primary reason.

First comment is that when we look at spending on Health, we need to open our scope to all of health, not just Hospitals. The money the state spends on "health" includes the money spent in the Department of Health, money spent on local government community health centres of which a large number are registered organisations now which draw funding from the state government and the general increase in community and prevention programs that all draw some cash. When a government increases the number of people working in the beaurocracy, that's an increase in cost to Health but no clinicians are involved. All the public education and preventative programs are all funded out of Health as well.

The first and most obvious one is population increase and the aging population. More people means greater demand for the services, aging means greater demand on government funded Paliative care and nursing homes.

You referred to obesity, that is from what I understand a large factor (no pun intended) in the increasing complexity of cases. Someone comes into an ED with a chest infection or whatever, you treat it and move them on. When they weigh 180kg and have a dodgy ticker, high blood pressure and a weak immune system everything gets messier and takes longer. I think the clinical term I've heard used is "co-morbidities" which as I understand it means they have lots of shit wrong, not just one thing that can be treated.

As population expands and become more acute with the illnesses, hospitals have increased in size and consequently employed more people. Cost of salary and wages in the single biggest cost.

What will be interesting is whether the growing trend away from bed based hospital care toward community based treatment (including in the home) will have much impact. Some of the models of care in Victoria are, as I understand it, Australia best practice, particularly in Mental Health. (WPT may have me committed for that )

[Culprit]

Go to any emergency word and you have poor people in there seeking medical treatment for issues like the common cold. The system should push them to bulk billing super clinics.

We have many emergency beds taken up by mentally ill patients that need treatment and the reason they are there is we closed most of the mental facilities to save money. It's coming back to bite us. Thanks Jeff.

Obesity is a product of our culture and gets a huge boost from advertising and it's targeted mainly at the poor. Wealthy people tend to eat better. I know as I have been on both sides of the fence. Throw in other mental issues. It's easy to point the finger at fat people and saying they shouldn�t eat this or that. I�m fat and eat a third of what my mate does and he is skinny as. You have to help not force people to change their lifestyle and letting them live in cess pools is not the answer.

Private health insurance is a scam always has been. It's great until you have to make a claim. What�s the difference between a hospital gown and private health insurance? Nothing, they both hardly cover you.

The ageing population has created an environment of nursing homes with pretend nursing staff, many of whom are aliens with regulations that are the worst I have ever seen. My Father is in one and the care is hopeless. The staff in there are simply not qualified and are only there because it's cheap labour. The Operators of these facilities are making squillions whilst people suffer in misery. Euthanasia is a better solution to what I see many of the elderly have to cope with in these cockroach infested things called nursing homes.

[think positive]

good easy cheap medicine is bad economics, (directed at the pharmacutical (stuff it drug) companies)

the sooky rights people will be up in arms if you try to force people to look after their health (even the cheap way, walking, eat less, )

and they government doesnt want you to stop smoking, no matter how ugly the packaging, because taxes are good!

ditto alcohol!

its a greedy vicious circle.

models should not get paid more than surgeons.

but they do.

(culprit, i agree, those with the common cold in the emergency dept should be sent to bulk bill centres, its ridiculous, and laziness) -yes .....fill the name, i know some cold symptons can lead to worse. but see the locum first.

dont get me started on nursing homes, its still too raw!

you get what you pay for, we have the insurance we have to have for tax reasons, and money put away in case we need treatment. ditto the dentist. somethings are worth paying for.

decent health care is no. 1

[stui magpie]

[Tannin]

Good contributions, gentlemen. (Including you, TP, 'cause you is a genulman an' a lady.) A couple of random points.

(1) When I mentioned the bad health industry (not just junk food! there is lots more to it) I wasn't talking about obesity, though that is certainly a relevant consideration too. I was talking about heart and circulatory system health. Sugar, saturated fat, sodium: almost the entire food industry (save for unprocessed fresh producers) loads stuff up with sugar, salt, and/or saturated fat. All three contribute massively to cardiovascular failure and bring forward billions of dollars in health care cost each year.

Almost every food item you buy in the supermarket - from a can of soup to a potato salad - is loaded with way, way, way too much salt, and that kills people. Worse, the manufacturers are increasing that already deadly contamination. (link here.) The cost of this dysfunctional way of doing business is massive - it is estimated that cutting the average sodium content of processed food by less than 10% in the USA would save 32 billion dollars, prevent almost half a million heart attacks, and more than half million strokes. And that's a piddly little 10% cut that no-one would even taste or notice, let alone care about.

Multiply that huge saving by a similar one with saturated fat, and again with added sugar - both are massive heath risk factors, and governments do sweet FA about them because they depend on donations and graft from the (nearly all foreign-owned) manufacturers, and are terrified of their persuasive power.

(2) On a completely different tack, Stui (in this thread and the other one) sort-of-almost-hints that taking money out of the health system is unimportant so long as we are not taking any out of direct clinical care. To overstate his case for the sake of clarity, it suggests that public servants in non-clinical roles are wasted money, only doctors really count. We should stop wasting money on shiny-bum bureaucrats and direct everything to where it will maker a real difference.

^ That's probably not a fair summary of Stui's view, which is just as well, 'cause it's massively wrong. I haven't seen figures for this, but you can safely bet Sydney to a brick that a dollar spent in appropriate health ancillary care programs returns real benefits two, five, and ten times greater than the same dollar given to a hospital. I'm talking preventative health care here: infant welfare clincs where mothers learn how to keep their kids from getting sick; AIDS prevention campaigns; sex education in schools; work on improving the standard of food sold in school canteens; work on anti-junk food measures; school sport participation programmes; creating leafy walking tracks through ugly suburbs to encourage the habit of healthy exercise; the Life Be In It campaign; mental health workshops; better update training for GPs; Sunsmart; David Parkin talking about early detection of prostate cancer at half-time in footy broadcast; the Quit Line; and so on and on and on. All of these things return, per dollar spent, much, much more than an extra doctor or an extra hospital bed. In a very real sense, money spent on hospitals is treating the symptoms: money spent on prevention is treating the disease itself - or rather, the huge social ill-health disease that causes most of the diseases doctors treat.

[Morrigu]

Would agree with all that others have said especially Tannin with regard to:

" the ceaseless invention of new (and ever more expensive!) ways to treat disease, ways which Joe Public (quite understandably) demands by used right now!"

This is one of the greatest problems and from where I sit it is two fold:

The public have greater access to health information (which is good in many respects) thanks to the Internet BUT the quality of the information is variable (Dr Google comes up with some weird and wonderfuls at times!) and so the information is taken as gospel "because they read it on the net. Clinicians are often pressured into ordering �this test or that test or this drug or that drug" and if they refuse well many go "doctor shopping" until they find someone who will.

We expect everything to be "fixed" with a pill (broad generalisation acknowledged) and as a result polypharmacy is a big problem especially in older patients, as they will often get prescriptions from multiple sources -in addition to self medicating. The drug companies take full advantage of this!

The problem with this is that treating clinicians often have a lack of awareness of the patient�s complete drug regimen which often results in duplication, drug interactions and a failure to identify adverse drug reactions - which in turn leads to hospitalisation.

Our desire to be instantly cured has also most certainly resulted in antibiotic resistance as many insist on antibiotics for a virus e.g. common cold. The cold will run its course but because it usually disappears a few days after starting antis (which it would have anyway) the need for antibiotics for everything is reinforced and the cycle continues! And with increased resistance the need for better more expensive antibiotics continues.

I don�t know if it is a fear of litigation (my feeling is it is) but diagnostic tests which have increased in number and price are over-ordered. This may sound simplistic but the inappropriate ordering of diagnostic tests is a big problem and very costly!

And it is not just tests but treatments as well.

With the increase in technology and pharmaceuticals we have the capacity to resus patients who would not have made it to hospital before � not for one moment am I suggesting that this is a bad thing (but sometimes it is � false hope that turns to pure futility is tough for all, especially families).

No one wants to pay more tax, but if we continue down the path of expecting modern medicine to be able fix all our ills (almost instantaneously) without accepting some personal responsibility for our behaviour and actions and acknowledge and be willing to contribute enough so that we have a decent affordable and accessible health system we will very soon be unable to cope and will be in American mode!

[Morrigu]

[stui magpie]

[watt price tully]

A couple of points. Great thread BTW.

Let me start with this:

HEALTH IS A SOCIAL ISSUE NOT A MEDICAL ONE

1. We treat more people more quickly than we have ever done.
1.1. This is a good thing.
1.2 Many years ago for example a simple operation like a hernia repair would've meant quite a long spell in hosital. These days it can be in & out, more safely & better performed.

2. As Stui noted staying in the ED if you need to be admitted is dependent on the receiving unit having capacity. They are invariably blocked due to the lack of funding & services for the aged. Sort that problem & you sort most of the ED waiting time issues if you need to be admitted.

3. In terms of the so called psych pt's going to the ED: Most admissions go direct to the psych inpatient unit from the community.
3.1 GP's, Private Psychologists etc, Lifeline & too many others send people direct to the ED to be seen when community based options are a much better way to deal with issues. That is one is often dealing with staff or service anxiety rather than a persons needs.
3.2 Much of the so called mental health issues are a result of government cuts to things like housing, aged care, migrant services, domestic violence, drug & alcohol supports. This direcly results in more people going to ED's for housing, Drug & alcohol issues etc. Both major parties are responsible but as always the Libs are worse than the ALP (both are bad) in terms of cuts to the services noted.
3.3 As more cuts occcur to welfare then expect as a direct consequence more ED presentations

4. Non urgent ED presentations
4.1 GP's often don't bulk bill.
4.2 Many people can't afford to see GP's so they present to an ED

5. Mental health is a heterogenous term, it's an umbrella term: covers lots of things.
5.1 Can cover "I just want to talk to someone" to active suicide & florid psychosis. Mental health in an ED generally deals with acute issues. We see lots of people who take overdoses, self harm, have used speed or ICE & need medical attention. Medical & mental health needs need to be addressed. If they need medical attention like everone else they get medically attended to & if needs be, admitted.
5.2 Alcohol is the single biggest reason for substance & illness related issues & lots of people present alcohol affected, no where to live, alcohhol related disease etc every day in all Emergency Departments. They contribute to bed blockages. Bloody alcohol drinkers
5.3 Alcohol Industry, Hotel association, liquor industry etc has a lot to answer for as do governments who are too scared to put some real limits on retail liquor outlets. Deal with this & you can deal with a lot of health & social issues.

6. The mentally ill do not block ED's per se. No one where I work stays in an ED longer than 24 hours. No one period. This is a good thing.
6.1 If there are no compoications & someone needs to be admitted to mental health a lot are in within 4 hours.
6.2 There can be complications: last night I dealt with a kid who took 140 mg of olanzapine (10 mg is his usual dose) - a sedating anti psychotic. He was really unable to be assessed after coming to the ED at 2pm yesterday till after 8 am today. Tried to assess him a few times. Got somewhere: established he was not suicidal & had somewhere to go but this was not a full assesment by any stretch. I would think he would be discharged if there are no acute risk issues
6.3 Another guy came in by police who'd used speed. No psych histroy. He was psychotic but cooperative. Many pt's can be discharged with medications & follow up, some the medication are insufficent to treat the symptoms & need morre time. This may take more than 4 hours may need to be admitted. One needs to keep this type of presntation in an ED till you see the results of the treatment commenced. Medically unwell people whether due to intoxciation by drugs or alcohol can't go to mental health inpatient units as they are not medical units, their symptoms may well resolve etc. Hospital admission is always a last resort.

7. Need more staff in ED's, more resources in the community in mental health drug & alcohol, housing etc.

One way of funding is to adress the notion that those who contibute to the problem need to pay for the problem they benfit from:

Too may places & businesses like hotels, gambling places etc like to privatize the profit but socialize the costs.

Address these & this is part of the answer.
Deal with the AMA is another way of reducing costs
Tax fast foods & soft drinks big time
Tax alcohol big time

A far as the social is concerned bring fitness to schools - rid the schools of religious education / chaplaincy & bring in non competitive as well as competitive fitness. Start from prep onwards.

[watt price tully]

[sixpoints]

What is so wrong with paying taxes? It somehow seems a given now that everyone expects year after year to increasingly pay less tax.
Taxes provide for the community. I would happily pay more tax if I knew it would provide better health care, better education, better infrastructure.
If we persist in this lunacy of shrinking the tax base, we will all be worse off. The tax rate for the highest earners has shrunk markedly, yet our services are increasingly funds deprived.
Imagine a few extra billion a year on preventative medicine, community health care, health education, mental health programs/services.
Money raised & spent on keeping people healthy and out of hospitals.

[stui magpie]

[HAL]

[Tannin]