Grattan Institute

Opening borders early is the “gambler’s option”

October 5, 2021 by Madeline Lucre Leave a Comment

Grattan Institute modelling shows it would be dangerous for Australia to open up its international borders before at least 80 per cent of the population is vaccinated.

The model simulates the spread of COVID-19 within a partially vaccinated population using hospitalisation and intensive care unit (ICU) admission rates from more than a year of COVID-19 data from Australian ICU units.

It found the only scenario out of 12 where the virus is managed, with hospitalisations and deaths kept down to reasonable levels, is when at least 80 per cent of the population is vaccinated.

The authors of the study describe scenarios with a 70 or 75 per cent vaccination rate as the “optimist’s and gambler’s scenarios”.

“Opening the borders is a one-shot gamble: if you make the wrong call, the virus will quickly spread and all the good work and hard yards of living through lockdowns over the previous two years will have been wasted,” said Stephen Duckett, Director of the Grattan Institute’s Health and Aged Care Program.

“The difference in virus spread, hospitalisations and deaths between opening at 75 per cent and at 80 per cent are big, but the wait between the two thresholds may only be a month or two. This is why we recommend an 80 per cent vaccination rate as the threshold for opening up.”

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

May 18, 2021 by Rayan Calimlim Leave a Comment

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

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

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

Immediate fixes with no guarantees

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

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

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

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

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

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

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

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

Small steps towards a better system

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

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

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

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

A local network of health department staff will be embedded in the regions, and there will be a network of 500 “care finders” to help older Australians get the support they need.

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

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

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

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

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

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

Next month’s federal budget is the time to stop talking about aged care and start fixing it

April 20, 2021 by Rayan Calimlim Leave a Comment

Australia’s aged-care system is in a state of a disaster. The aged care royal commission’s final report, released last month, is just the latest in a decades-long string of depressing reports and inquiries exposing horrific abuse, neglect, and systemic failures.

Aged care needs a complete overhaul. Piecemeal reform will not be enough. Although the two commissioners didn’t agree on everything, they did agree on the fundamental reforms needed to throw out the old paradigm of rationed care, which has left too many older Australians with inadequate care — or none at all.

In a new Grattan Institute report, we navigate the commissioners’ disagreements and identify four key criteria for transformational change.

Of course, fixing aged care won’t come cheap. We also set out some ideas as to how the government could secure the billions of additional dollars needed every year to fund a better aged-care system. In this regard, next month’s federal budget offers a crucial opportunity for the government to step up.

Forging a clear path to change: 4 steps

First, the government must develop a new Aged Care Act that enshrines the rights of older Australians and includes a universal entitlement to needs-based care. Reforms to create a single new integrated aged-care program that includes both home care and residential care categories would make care easier to access. This would also help ensure high-quality care for all older Australians who need it, without waiting times or co-payments for care.

Second, the government must introduce new independent governance arrangements, including independent pricing, independent quality standards, independent oversight, and regional governance structures. This would help address poor regulation and failures in the current market-based system that have meant many older Australians haven’t been getting the level or quality of care they need. Better governance and enhanced transparency would help create a properly functioning aged-care system dedicated to providing high-quality care.

Third, the government must announce major reforms to the aged-care workforce. It must set and enforce minimum care hours per resident in residential aged care, set up a national registration system for all personal care workers, and mandate that all aged-care workers complete Certificate III training at a minimum.

Finally, the government must announce a massive boost in aged-care funding — and detail how they’re going to finance it.

Coming up with the cash

People receiving care should contribute to their ordinary costs of living, such as accommodation. But the government should pay for their care costs, just as the government pays for patients’ costs in public hospitals (through Medicare).

This approach would provide universal insurance for people with high care needs, and would reduce the need for precautionary savings in older age, because people would not need to worry about how they are going to fund their possible care needs.

The royal commission identified a A$9.8 billion annual funding shortfall in aged care, and that figure will only increase as Australia’s population ages.

This funding gap could be financed through some combination of a Medicare-style levy on taxable income, changes to the pension assets test, reductions in tax breaks on superannuation, or other mechanisms.

The royal commission recommended a 1% aged-care levy on personal income tax, just like the Medicare levy, as a way to share costs across the community. This would raise about A$8 billion per year and cost the median taxpayer about A$610 per year.

Other tax measures targeted at wealthier older Australians would also help ensure equity in funding a better aged-care system.

The average household headed by someone aged 65-74 now has more than A$1.3 million in net assets. That figure has more than doubled in the past two decades. Counting more of the value of the family home in the pension assets test (a means test that determines your eligibility for the pension) above a certain threshold — such as A$500,000 — would make the pension fairer. It would also save the budget up to A$2 billion a year, which could be reallocated to aged care.

The government could also wind back excessively generous tax breaks for older Australians in superannuation, which result in only one in six people over 65 paying any income tax.

Superannuation earnings in retirement — currently untaxed for people with superannuation balances of less than A$1.6 million — should be taxed at 15%, the same as superannuation earnings before retirement. This would improve budget balances by about A$6 billion a year today, and much more in future.

Surveys consistently show Australians are willing to pay more tax to fix aged care.

Money has to be spent wisely

Pre-budget leaks suggest the government is prepared to invest additional billions in aged care, but the amount foreshadowed in a media report over the weekend — A$10 billion over a four-year period — is below what experts identify as necessary to fix the problems revealed by the royal commission.

Just as important, if the additional funding is not accompanied by system reform, then an opportunity will have been wasted, and the spending will be wasted on system inefficiencies and excess management fees rather than on improved services for consumers.

The time is now

Properly administered, extra funding could transform the aged-care system. It could clear the 100,000-long waiting list for adequate home care, provide higher-level care at home for longer, employ at least 70,000 more aged-care workers, lift the amount of care per resident, and ensure a qualified nurse is on site 24/7 in all residential care homes. But achieving these needed changes will require more than what appears to be on offer in the pre-budget leak.

The government must seize this moment. It must sharpen its pencil and take this historic opportunity where there is substantial public support for transformative change and fund the necessary reform fully. Next month’s budget should include policies — and funding — to create an aged-care system in which all Australians can take pride.

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

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

New aged care data on hospitalisation rates show significant problem areas in residential aged care

February 2, 2021 by Rayan Calimlim 1 Comment

The Royal Commission into Aged Care Quality and Safety released new data overnight comparing hospitalisation rates from residential aged care facilities.

The report found 36.9% of nursing home residents presented to an emergency department at least once in 2018-19.

It’s one of many research papers specifically commissioned and published to inform the Royal Commission, which will release its final report by February 26 this year.

The findings are a welcome addition to the dearth of information about the quality of aged care in Australia. It’s unacceptable that it’s taken a Royal Commission in 2021 to uncover simple information about hospitalisation rates.

The report highlights key metrics about the sector’s performance. It points to the next stages in the journey where information about the performance of individual residential aged care facilities is published, and where further investigation is undertaken locally about improving the interaction between residential aged care, general practice, and hospitals.

Aged care in Australia suffers the same accountability deficit as other aspects of human services, but that is slowly changing.

Last week the Productivity Commission released data comparing states on a range of indicators including availability of federal government funded aged care and consumer satisfaction with aged care services.

What the data can tell us

The report found about 3.4% of residents were admitted to hospital for a pressure injury, about 2% for weight loss, and 0.5% for an adverse medication event in the same time period. These rates are just the tip of the iceberg, as they represent those who were serious enough to be hospitalised and don’t include people who were treated in the nursing home and didn’t require hospital admission.

Importantly, the report says there are many facilities which are outliers on one or more of these measures. There are some facilities where the residents have significantly higher rates of hospital admissions for pressure injuries, weight loss, or adverse medication events than others. The report does not identify these but, in the medium term, the public has a right to know which residential aged care facilities are of concern and which are managing these quality risks well.

The report also found 10.5% of residents were admitted to hospital in 2018-19 because of a fall, up from 8.5% in 2014-15, and 5.4% for a fracture.

The data can’t tell us everything

But we need to be cautious about these findings. We cannot use the rate of falls and other injuries as the only indicator of quality care.

One way residential aged care facilities can minimise the risk of falls leading to hospitals admission is by better care and assessment of residents. And on the other hand, facilities should resist the urge to overreact by stripping residents of their autonomy and not letting them move around, nor letting them take any risks at all. Quality care also means treating residents with dignity.

The data also cannot answer the question of how many emergency department presentations could be avoided with better staffing, nor whether involvement of GPs, geriatricians or health outreach from the emergency department could’ve prevented any of these presentations.

Another risk of these data is they’re very health-oriented. The health sector, and especially hospitals, have lots of good data and so it’s easy to develop measures relating to hospitalisations. As good as the published data are, the risk is that decision-makers will focus on what’s measurable, rather than what’s important.

Reform in the aged care sector must have a rights basis, as we at the Grattan Institute pointed out in our 2020 report on rethinking aged care. The full range of residents’ rights needs to be promoted and protected.

More work needs to be done on measuring whether the rights of older Australians are being upheld alongside these hospital-oriented measures, and resident-relevant measures of quality including use of agency staff, staffing ratios, and dealing with individual preferences and differences.

What now? The public needs access to aged care facility performance

This report was prepared for the Royal Commission, so it mostly highlights issues and demonstrates what can be done. The next step is for the aged care regulator to pick up where the Royal Commission has left off.

In light of calls for increased transparency and accountability in aged care, the regulator should provide feedback to all nursing homes about where they stand on these metrics and then identify relative performance publicly.

Now these data have been collected and shown to be relevant, it’s now unethical for the regulator to withhold this information from the public, especially when the rhetoric about aged care is about promoting choice in a market where people choose their residential facility. Although providers are asked to report against quality standards to the regulator, very little of this information is passed on to the consumer.

The aged care regulator should set a target of publicising performance metrics for the December quarter 2021, and do so on an ongoing basis.

Performance metrics should also go beyond hospitalisation rates, and include information about staffing numbers and ratios as is done in the United States with its star rating system. They should also include the number of complaints and assaults — information which is currently unavailable to older Australians needing care.

Stephen Duckett, Director, Health Program, Grattan Institute

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

Victorian response to COVID-19 an international envy

December 2, 2020 by Rayan Calimlim Leave a Comment

Victoria dealt with its second wave of COVID-19 extremely well by international standards.

Only Vietnam and Hong Kong did as well as Victoria in defeating a second coronavirus wave.

Of the 215 nations and territories that have reported COVID-19 cases, 120 have experienced clear second waves or late first waves that began in July or later according to data from national ministries of health and the World Health Organization.

Of these 120, only six have definitively emerged from their second wave: Australia, South Korea, Japan, Hong Kong, Vietnam and Singapore.

In other parts of the world the severity of the second COVID wave has been grim. By late October, the worldwide tally of cumulative cases was adding one million new cases every three or four days. Just seven countries reported fewer than 50 new cases: Australia, China, Nigeria, Singapore, Ivory Coast, Zambia and Senegal.

At the same time, France and the United Kingdom each reported more than 26,000 new cases, and 20 European countries posted all-time daily record numbers.

Some European countries have reported daily case numbers 25 to 30 times higher than during their first wave.

Stephen Duckett, Director of the Health Program at the Grattan Institute says Victoria’s achievement in getting down to zero or near-zero community transmissions is unprecedented.

“No other place in the world has tamed a second wave this large. Few have even come close.”

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

May 8, 2019 by Nurse Uncut Editor 1 Comment

The Morrison Government’s Medicare Guarantee fund is just a dishonest accounting trick, says the Grattan Institutes’s Stephen Duckett.

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.

The Medicare Guarantee Fund is nothing more than a rebadging exercise.

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.

Based on the sketchy information so far available, this fund appears to be no more than an accounting trick.

What should a Medicare guarantee look like?

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

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

Stephen Duckett, Director, Health Program, Grattan Institute

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