Healthcare in the home is one lever the feds could start pulling to help solve the states’ ED access and bed block issues if it could just manage the politics a little better.
If this week’s Healthcare in the Home Society conference in Sydney highlighted one thing it would be that we now are getting very good at understanding how to manage patients who end up in hospital but can be successfully and often better managed in their homes.
We also know that scaling out this expertise would significantly improve our problems with bed block and ED access over time.
But, as usual, we have some fairly sticky political problems to navigate, most of course, involving money, who gets it and how it’s distributed.
You’d think that, given the upside for our significantly clogged-up hospital system and for patients, both the state and federal governments would be jumping over each other to at least start leveraging just how much most hospitals are now engaging with HiTH.
The US covid and post-covid experience with HiTH is proving out just how effective funding the concept might be for our healthcare system.
The US is generally a kicking post for any evidence base of good healthcare policy because of its disastrously corrupted and complex private health funding system, but these burning platform issues in the US have led to a lot of innovative thinking on the part of their federal government.
It has led the US to innovate in digital health and interoperability many years before Australia, and that appears to be helping them lead the way in evidence and thinking about HiTH as well, in many respects.
The US government funding paradigm for hospitals isn’t really comparable to Australia because health management organisations (HMOs) – which are vertically integrated private health insurers running everything in a line from a pharmacist, allied health professional and GP all the way to the hospital and back – confuse the picture a lot, so the following is highly simplified.
But it’s relevant.
During covid the US government wisely decided that it needed to fund services in the home with some sort of parity with how they funded beds in bricks-and-mortar hospitals.
When covid ended, the government didn’t stop doing that, largely because what it discovered was that the economics of doing it and the patient benefits were both a long way into the positive during covid and after.
As a result, the US is now a vast evidence base for Australian healthcare policy-makers to analyse and think about with respect to HiTH.
And the evidence is that funding HiTH beds on par or near par with how you fund beds in a bricks-and-mortar hospital works very well economically for people running and paying for hospitals, and even better for patients in terms of their wellbeing and outcomes, if they are identified and managed in the right way.
In Australia, a hospital is funded for a set number of beds, whether those beds are identified as being at home, or in the big shiny building uptown. So, if you have more at home you get funded for less in your hospital. It’s one inflexible number.
That’s a big problem for hospital managers and state governments because if you expand your HiTH program too much you won’t be able to fund your beds in your bricks-and-mortar hospital to the extent that you may need, at least in the near term. Your ED might get a lot more clogged, and your access block will likely get even worse because you have a lot less beds onsite.
Or, your HiTH program might turn out to be so successful that you have too many spare beds in your hospital and that will somehow effect your status and funding.
That’s not an impossible scenario.
In the US in some regions bricks-and-mortar hospitals are being mothballed because the HMO has become so efficient in treating its patients outside the hospital in that region.
It’s not just HiTH that is causing that effect – vertically integrating general practice and allied health with a much better platform for healthcare data sharing between providers and patients helps a lot too – but HiTH is a significant factor in the trend.
HMOs love HiTH, something which the more astute reader might associate with just how much our local private health insurers – Medibank most notably, but they all have it in their strategy decks now – are pushing the concept and starting to build out their own HiTH service provision as bait (benefits) for new insurance customers.
The US system effectively recognises both services as important and funds both publicly, outside the HMOs pushing it, for pretty much the same amount per bed, but does not restrict a hospital by enclosing all beds in the one envelope.
In other words, a hospital can expand its HiTH program as much as it likes in the US and not be punished by a bed limit that is largely tied to the bricks-and-mortar component of their servicing.
Interestingly, that is not blowing out public hospital bed budgets as many people expected it might.
That can’t happen here under our current public hospital funding paradigm.
What’s the problem with doing some version of what the US is doing then and tweaking our funding paradigm a bit?
The politics of fear. Fear that such a change would blow out hospital funding suddenly and massively and people would be blamed.
Also, you’d imagine, the fear of such a big change to such a set-in-stone federated funding system, where states will be states and can’t seem to herded in any manner by the federal government into any meaningful alignment for obvious national efficiencies in our healthcare system.
Another problem we have is that virtually every state and territory has a different view on how they individually manage and fund HiTH within their hospital systems.
A lot can go wrong in such a fragmented environment for sure.
Changing it all in some sort of Big Bang way might be like if you were the federal health minister who puts Ozempic on the PBS for everyone who actually would benefit from being on it.
The long-term ROI to the healthcare system and benefits for Australian patients would, based on emerging evidence about this drug, be revolutionary in time.
But you’d almost certainly blow the PBS to smithereens within a year or so. No one would applaud you for that. The benefits of an initiative like this are a long-term game – significantly less chronic disease in time for a younger cohort of patients coming through now. Anyone involved today would be crucified.
Mark Butler already knows how much potential there is in the barrage of GLP-1 drugs that are on their way to our shores (Ozempic and Mounjaro are just the start) and he has already hinted at some sort of limited listing for certain conditions at some time in the future. (Ozempic is listed for type 2 diabetes).
To even hint at this was bold.
Apparently the Department of Health and Aged Care are following the evidence base for HiTH are closely watching whether public funding for HiTH in US, which has remained in place since covid, will continue past this December when it is being reviewed.
It might get tricky if they don’t make sure the funding is firmly in place for a few more years before January 20 next year. That’s when Robert F Kennedy Jnr will reportedly be taking over the running of health in America.
It’s easy to sit back and proselytise about how simple this idea feels and point to an increasingly convincing evidence base emerging both here and overseas on HiTH, but I wouldn’t want to be the state or federal politician or bureaucrat trying it in today’s febrile hyper-partisan cost-of-living crisis environment.
But I don’t think that with such clear evidence emerging overseas and locally, and so many local institutions getting so good at it on a limited scale, that I’d do nothing either.
There are some levers in healthcare being facilitated by technology now that the government can’t ignore much longer. AI is a very big one which I won’t discuss here, but virtual care facilitating HiTH is maybe the next biggest one to AI.
The Victorian government seems to be leading the way in funding HiTH for its hospitals at the moment. It is doing that because it sees the economics and patient benefits, notwithstanding that the bed funding model doesn’t suit expansion of the idea that much.
But the current public hospital bed funding model doesn’t suit a lot of things that hospital networks are starting to fund because of an ever worsening breakdown of the economics of continuing a bricks-and-mortar centric hospital system, largely disconnected from primary care.
A lot of hospital networks in rural and remote areas are now subtly funding local GP services in an effort to reduce the pressure on their local hospitals although strictly, GP funding is a federal responsibility.
It feels a lot like the evidence and the will on the part of all the relevant parties involved in Austraslia might be staring to align on the issue.
Testing a better funding paradigm for HiTH does not have to be revolution.
It could be done in pilots and trials in relevant areas so we can gain some local confidence that we wouldn’t have the Ozempic-style PBS blowout outlined above.
The federal government and DoHAC might want to think about how they could help facilitate such trials or evidence building and maybe dedicate some funding to such a program, if they aren’t already of course.
They are thinking innovatively about transforming our the healthcare system these days.
No funding available for this perhaps given we have already had a record increase to DoHAC’s adminstered healthcare spend this year?
Urgent Care Centres have been funded and built at a cost to the federal government of over $300 million so far and one of the major reasons listed in DoHAC’s own website for Urgent Care Centres is to reduce the pressure on our hospital EDs.
For that money we are planning to have 87 UCCs despite that fact that the so far operating 70 or so have provided no data to suggest that they are relieving any pressure on locally located hospital EDs.
We have nearly 700 public hospitals in Australia which suggests that the UCC program, even if it does start working for local ED loads, will not be able to put much of a dent in the problem overall.
What might is a well-coordinated, state-by-state aligned and funded approach to HiTH in this country.