Friday, May 23, 2014

The ideal method for evaluating the benefit of co-payments is a proper trial

John Kaldor, Nicholas Zwar 
The Australian,  23/05/2014 

THE government’s proposal for a $7 co-payment for GP visits and laboratory tests is one of the
most hotly debated items in last week’s budget.

Putting aside the “broken promises” issue, most of the criticism of the co-payment has revolved around its fairness. In a purely mathematical sense, a co-payment is a proportionately bigger hit for those on lower incomes, but there is a more fundamental question. What will a co-payment actually do to people’s health?

Basic economics says that a cost increase will reduce demand, which means fewer doctor visits and tests. On the surface, that sounds like it would be unhealthy, but what if people were having consultations they did not need?

The government has in fact claimed several major health bene fits for the co-payments. It believes people will look after their health more if they have to contribute directly to the cost of medical services, and GPs with fewer patients will provide better care to those who do show up.

On the other hand, critics of the co-payments say that health will suffer because people deterred by the co-payment will miss out on care that they need to maintain health. What does the scientific evidence tell us about who is right?

Medical science has well- established techniques for deciding what works and what doesn’t. The ideal method for evaluating health benefit is the randomised trial, which compares groups of people allocated to receive competing forms of “intervention”.

The only large-scale randomised trial of co-payments ever conducted was the Rand Health Insurance Experiment, which took place in the US in the late 70s and early 80s. It found those assigned to the co-payments group used fewer medical services than those with free care. Those on lower incomes had poorer outcomes in several areas of health and for people on higher incomes there was no difference in health outcome.

There was also no difference between the free and co-payment groups in the extent to which people looked after their own health in areas such as diet and smoking.

The Rand trial found that the co-payments reduced use of both needed medical care and unnecessary care, suggesting that people may not be good at making the distinction for themselves.

The Rand trial provided the most methodologically rigorous evaluation of the health effect of copayments, but  it took place more than 30 years ago, in a health system very different to ours.

Since, there have been nearly 50 studies, mainly from Western Europe and Canada, that looked at the impact of co-payments.

Although they did not use the randomised trial methodology, this body of evidence is highly relevant to our current debate about the impact of co-payments.

The studies are consistent in showing lower levels of service usage when co-payments are introduced, and are also generally consistent in showing that people on lower incomes reduce service uptake to a greater degree.

For various methodological reasons, the studies are much less informative about whether the reduction in service uptake systematically led to worse health in the population.

To draw such conclusions, longer timeframes and more detailed data are required, and few studies have had sufficient scope to do so. What is clear is that there is absolutely no evidence introducing a co-payment has any benefit for people’s health.

If a pharmaceutical company proposed marketing a drug that had no proven health benefit, and there was some evidence that it was actually harmful to certain population groups, it would not get past first base with regulatory authorities or clinicians.

That is more or less the position we are in with regard to the health impact of co-payments.

In these circumstances, the argument about whether they should be introduced can certainly not be based on their potential for dir ectly improving health.

If co-payments are to be introduced, the current state of the evidence suggests the very process of their introduction should be through a form of trial that is properly resourced, carefully monitored and perhaps restricted in some way before full-scale implementation is considered.

We now have the ability to track health and health service usage through electronic data bases that protect confidentiality.

If there is any sign from such a trial that people in need of care are being deterred from necessary medical attendance as a result of co-payments, let alone experiencing worse health outcomes, the government would then be in a position to react quickly and make needed modifications to maintain confidence in our health system.

John Kaldor is professor of epidemiology and Nicholas Zwar professor of general practice at the University of NSW.

Tuesday, May 13, 2014

Submission to RET Review - retain RET and don't burn native forests for fuel

13 May 2014


This is my brief submission to the Renewable Energy Target review that you are conducting.
The whole purpose of the Renewable Energy Target (RET) is to address climate change and reduce carbon pollution by bringing more renewable energy into our electricity supply in a gradual and predictable fashion that encourages investment.

The Coalition has promised at the two most recent Australian elections to retain the target. I expect the Government to honour all its climate promises.

I would like the target of 41,000 gigawatt hours of renewable energy by 2020 retained, or preferably be increased to 60,000 gigawatt hours, so that we can move faster to address climate change.
I understand that the present target is costing the average household about an extra dollar a week for electricity.  I am more than happy to pay this small charge to clean up our power generation and reduce carbon pollution.

Native forest wood products must not be classified as an eligible renewable energy source as there are significant net total carbon emissions resulting from logging native forests.  Forest destroyed by logging is not “waste”.  The natural value of forests, their biodiversity, the water they produce and the carbon they store is far more valuable than woodchips and the small proportion of sawn timber produced by logging them.

Burning logging residues resulting from logging native forests will increase carbon emissions and further encourage ongoing logging, destruction and degradation of Australia’s native forests, some of which have been found to be the most carbon-dense in the world.

Peter Campbell
Surrey Hills, Victoria

Thursday, May 08, 2014

Australian needs a national Integrity Commission now

Add your voice to our call to clean up politics

It’s time to for a national corruption watch dog to clean up politics.

Politicians of all persuasions should recognise that the public interest is best served by a clear separation between politics and business.

Recent revelations by state ICACs make it clear that sadly this is not the case in Australia.

That’s why we urgently needs a national Integrity Commission to oversee anti-corruption measures at a federal level in the same way that state ICAC do.

The Australian Greens have called on both Liberal and Labor to urgently consider legislation for a national Integrity Commissioner in light of recent events in NSW politics.

An Australian Greens bill for a national Integrity Commission is already before federal Parliament. Among other integrity measures, the bill would establish a new Office of the Independent Parliamentary Adviser to advise MPs and Ministers on entitlements claims and the ethical running of their office that the public rightly expects. The adviser will also be tasked with developing a legally binding code of conduct for MPs for the Parliament to adopt.

Add your voice to our call to clean up politics:

To the Honourable President and members of the Senate in Parliament assembled:

The petition of the undersigned shows:

Politicians of all persuasions should recognise that the public interest is best served by a clear separation between business and politics.

The Australian public expects their elected representatives to act ethically and in the public’s best interest.

A National Integrity Commissioner would help ensure that this is the case.

Your petitioners ask that the Senate:

Urgently support legislation for a National Integrity Commissioner to oversee and implement anti-corruption measures at a federal level.

Online petition is here