We have recently been doing some work writing papers from a data set we gained through working with National Disability Services in a national survey they do with providers of disability services. We have recently published a paper from this data that explores issues relevant to price setting. This paper was written just before the price increase that was announced at the end of March.
The abstract is below and the full article can be found here.
Personalisation schemes and associated markets for social care have been a growing trend in industrialised countries over recent decades. While there is no single approach to marketisation of social care and personalisation, often funds are devolved to clients of care services to be used to purchase services directly from market. Such arrangements are vulnerable to market failures and ‘thin’ markets, causing the need for stewardship of the social care markets. We present findings from a 2018 survey of 626 care service providers in the Australian National Disability Insurance Scheme market on their experience of market conditions. Over 46% of respondents listed ‘addressing pricing’ as their top action for addressing market problems. Qualitative findings show that central price setting is detached from service delivery realities, affecting service quality and capability building potential. We argue that devolution of price setting to, or at least flexibility and discretion at, the local level is likely to be a key to solving pricing dilemmas in personalisation schemes.
A new paper I am involved in has just been published by Disability and Society and written with a bunch of amazing scholars at the University of Sydney. In this paper we explore issues of ableism within universities. We argue that little attention has been paid to how we can support people with disability to develop their careers as researchers. I have written previously about issues relating to gender in academia and I think that this is an area that is even more neglected.
When we reviewed the literature we found that there is little attention paid to this issue in terms of research. So in plotting a way forward we draw on personal testimonies of four of the authors who are researchers and who have experienced career challenges in part at least because of their disability. In the paper we develop a series of recommendations in terms of how universities might better support individuals with disability within the academy.
The abstract for the paper is below and the full version can be found here.
The academy should be a welcoming environment for people with disability. Across Australia, however, there is a current shortage of programmes supporting people with disability to develop their careers as researchers. This article critically investigates current practice and experiences concerning universities and the employment and career development of people with disability as advised by the literature, and how this practice aligns with the lived experiences of several of our authors. Our review of the literature utilising Scopus, PsycINFO and ProQuest databases found a deficiency of research attention on this topic, with only 16 relevant articles identified. This paucity of literary evidence has been augmented in the article by personal stories shared by four of its authors. By focusing on evidence-based measures with potential to support disability employment and career pathways throughout universities in Australia and elsewhere, this article challenges leaders to address ableism and to advance a more inclusive academy.
Every day Morrison’s Medicare freeze stays in place is another day that families are paying higher out-of-pocket costs to visit the doctor. If I’m elected prime minister, I won’t waste any time stopping Morrison’s cuts to Medicare.
Health issues always feature strongly in election debates, but what is the Medicare rebate freeze and how does it affect what you pay when you see a GP?
How Medicare works
Medicare is our public health insurance system and funds a range of services such as GP visits, blood tests, X-rays and consultations with other medical specialists.
The Medicare Benefits Schedule (MBS) lists the services the Australian government will provide a Medicare rebate for. Medicare rebates don’t cover the full cost of medical services and are typically paid as a percentage of the Medicare schedule fee.
GPs who bulk bill agree to charge the Medicare schedule fee and are directly reimbursed by government.
Those who don’t bulk bill are free to set their own prices for services. Patients pay for their treatment and receive a rebate from Medicare.
There is often a gap between what patients pay for services and the amount that Medicare reimburses (A$37 for a GP consultation, for example). This gap is known as an out-of-pocket expense, as the patient is required to make up the difference out of his or her own pocket.
Under an indexing process, the Medicare Benefits Schedule fees are raised according to the Department of Finance’s Wage Cost Index, a combination of indices relating to wage levels and the Consumer Price Index.
Organisations such as the Australian Medical Association (AMA) have long argued this process is inadequate and Medicare schedule fees have not kept up with “real” increases in costs to medical practitioners of delivering services.
The rebate freeze compounds this financial challenge by continuing to keep prices at what the AMA and others argue are “unsustainable levels”.
How did the freeze begin?
Although the Coalition is largely associated with this issue, Labor first introduced the Medicare rebate freeze. The freeze was introduced as a “temporary” measure in 2013, as part of a A$664 million budget savings plan.
The AMA, the Coalition and others loudly criticised the then government for the freeze.
However, on being elected to office in 2014, the Coalition froze the rebate after the failure of a number of proposed health policies. The rebate was frozen initially for four years, starting in July 2014, and extended in the 2016 federal budget to 2020.
Although the freeze was to be in place across the board until 2020, since 2017 there has been a phased lifting of the freeze for GP bulk-billing incentive payments (July 2017), standard GP consultations and other specialist consultations (July 2018), medical procedures (due July 2019) and targeted diagnostic imaging services (from July 2020).
What impact has the freeze had?
The freeze means those medical professionals who have not seen it lifted are reimbursed the same for delivering health services today as they were in 2014.
Professionals are paying more for their practices, staff, medical products, utilities and just about anything else that goes into running a medical service. But the amount paid remains static.
Those who have had indexing return to their services have seen only a limited rise in their value – A$0.55 for a GP consultation, for example.
In the run-up to the 2016 federal election, Labor made a similar promise and told voters they needed to “save Medicare” from the government’s plans to privatise the system.
This tactic was dubbed the “Mediscare” campaign. Some saw it as being highly effective in driving a swing towards Labor in the last election.
Last month the shadow health minister, Catherine King, blamed the Coalition for the freeze and argued this had driven up out-of-pocket costs for both GP and specialist visits, leading to more than 1 million people delaying or avoiding medical care.
There are a number of reports of GP practices and specialist services halting bulk-billing and patients having to pay higher out-of-pocket costs.
Yet the data on bulk-billing show bulk-billing rates have not fallen. In fact, the latest data show bulk-billing at an all-time high at 86.1%.
Some commentators argue these figures are misleading as they are calculated on services and not patients and so may be an indication of the increasing number of health services that use the MBS.
GP groups have welcomed the lifting of the Medicare freeze, but argue the indexation rates still fail to reflect the genuine value of general practice.
For those in areas such as diagnostic testing, the freeze is argued to have a profound impact. The Australian Sonographers Association argues that for ultrasound alone the average out-of-pocket cost for patients has increased by 117%.
Many experts argue that just giving a little more funding to GP services will not improve the quality of the Australian health care system and far more fundamental issues need attention if we are to see significant reform.
Although our project ‘Choice, control and the NDIS‘ completed some time ago, we are now starting to see some of the academic outputs follow. Just published is a paper by based on this data and other review data. In the paper we focus on the implementation of the scheme, some of the challenges that have emerged so far and implications for policy and practice. Below is the abstract and the paper can be accessed without a pay wall here.
Australia is immersed in its largest reform of disability services in a generation – the staged rollout of the National Disability Insurance Scheme (NDIS). Enacted swiftly to capitalize on rare bipartisan political and public support, the $AU22billion scheme promises to design and deliver disability services differently, with emphasis on service user choice and control. However, the scheme’s rollout is outpacing the readiness of service users, service providers and the agency charged with implementing it to achieve its stated aims, threatening to derail it. Research suggests issues arising in the implementation of the scheme can be attributed in part to the design of the policy and, in part, to how it is translated into practice, both making scant reference to lessons from comparable reforms. Reflecting on the implications of these findings for policy and practice, we explore a range of challenges that arise when embarking on large scale reform in an environment of tight timelines, high expectations, extant policy silences, competing priorities, and jurisdictional ambiguities. This paper adds to the growing body of literature on the NDIS by bringing in the views of participants, and elaborating on implementation challenges posed by its governance structure, system architecture, and administrative structures.
One of the very exciting things about working in an inter-disciplinary research group – as we do at the Public Service Research Group – is having the chance to work in areas that I know very little about. Recently I have been working with a couple of different teams in the space of ecology and conservation and a publication on this work has just come out.
This first work builds on a special issue that explored the use of “qualitative methods” for conservation. We welcome the intention of that special issue and argue that the collection makes many important contributions. Yet, the articles presented a limited perspective on the field, with a focus on objectivist and instrumental methods, omitting discussion of some broader philosophical and methodological considerations crucial to social science research. Consequently, the Special Feature risks narrowing the scope of social science research and, potentially, reducing its quality and usefulness. In this article, we sought to build on the strengths of the articles of the Special Feature by drawing in a discussion on social science research philosophy, methodology, and methods.
We start with a brief discussion on the value of thinking about data as being qualitative (i.e., text, image, or numeric) or quantitative (i.e., numeric), not methods or research. Thinking about methods as qualitative can obscure many important aspects of research design by implying that “qualitative methods” somehow embody a particular set of assumptions or principles. Researchers can bring similar, or very different, sets of assumptions to their research design, irrespective of whether they collect qualitative or quantitative data.
We clarify broad concepts, including philosophy, methodology, and methods, explaining their role in social science research design. Doing so provides us with an opportunity to examine some of the terms used across the articles of the Special Feature (e.g., bias), revealing that they are used in ways that could be interpreted as being inconsistent with their use in a number of applications of social science.
We provide worked examples of how social science research can be designed to collect qualitative data that not only understands decision‐making processes, but also the unique social–ecological contexts in which it takes place. These examples demonstrate the importance of coherence between philosophy, methodology, and methods in research design, and the importance of reflexivity throughout the research process.
We conclude with encouragement for conservation social scientists to explore a wider range of qualitative research approaches, providing guidance for the selection and application of social science methods for ecology and conservation.
The full text can be found via this link and is available open access (ie free!).
If you have seen science fiction television series such as Humans or Westworld, you might be imagining a near future where intelligent, humanoid robots play an important role in meeting the needs of people, including caring for children or older relatives.
The reality is that current technologies in this sector are not yet very humanoid, but nonetheless, a range of robots are being used in our care services including disability, aged care, education, and health.
Our new research, published today by the Australia and New Zealand School of Government, finds that governments need to carefully plan for the inevitable expansion of these technologies to safeguard vulnerable people.
Care crisis and the rise of robots
Australia, like a number of other advanced liberal democracies, is anticipating a future with an older population, with a more complex mix of chronic illness and disease. A number of care organisations already operate under tight fiscal constraints and report challenges recruiting enough qualified staff.
In the future, fewer numbers in the working-age population and increased numbers of retirees will compound this problem. If we then add to this equation the fact consumer expectations are increasing, it starts to look like future care services are facing a somewhat perfect storm.
Robots are increasingly becoming a feature of our care services, capable of fulfilling a number of roles from manual tasks through to social interaction. Their wider use has been heralded as an important tool in dealing with our impending care crisis. Countries such as Japan see robots playing a key role in filling their workforce gaps in care services.
A number of Australian residential aged care facilities are using Paro, a therapeutic robot that looks and sounds like a baby harp seal. Paro interacts by moving its head, heavily-lashed wide eyes and flippers, making sounds and responding to particular forms of touch on its furry coat.
Paro has been used extensively in aged care in the United States, Europe and parts of Asia, typically among people living with dementia.
Nao is an interactive companion robot developed in a humanoid form but standing just 58cm tall in height.
Our research explored the roles robots should and, even more critically, should not play in care delivery. We also investigated the role of government as a steward in shaping this framework through interviews with 35 policy, health care and academic experts from across Australia and New Zealand.
We found that despite these technologies already being in use in aged care facilities, schools and hospitals, government agencies don’t typically think strategically about their use and often aren’t aware of the risks and potential unintended consequences.
This means the sector is largely being driven by the interests of technology suppliers. Providers in some cases are purchasing these technologies to differentiate them in the market, but are also not always engaging in critical analysis.
Our study participants identified that robots were “leveraged” as something new and attractive to keep young people interested in learning, or as “a conversation starter” with prospective families exploring aged care providers.
But there are significant risks as the technologies become more developed. Drawing on research in other emerging technologies, our participants raised concerns about addiction and reliance on the robot. What would happen if the robot broke or became obsolete, and who would be responsible if a robot caused harm?
As artificial intelligence develops, robots will develop different levels of capabilities for “knowing” the human they are caring for. This raises concerns about potential hacking and security issues. On the flip side, it raises questions of inequity if different levels of care available at different price points.
Participants were also concerned about the unintended consequences of robot relationships on human relationships. Families may feel that the robot proxy is sufficient companionship, for instance, and leave their aged relative socially isolated.
What should governments do?
Government has an important role to play by regulating the rapidly developing market.
We suggest a responsive regulatory approach, which relies on the sector to self- and peer-regulate, and to escalate issues as they arise for subsequent regulation. Such engagement will require education, behaviour change, and a variety of regulatory measures that go beyond formal rules.
Government has an important role in helping providers understand the different technologies available and their evidence base. Care providers often struggle to access good evidence about technologies and their effectiveness. As such, they’re largely being informed by the market, rather than high quality evidence.
Many of the stakeholders we spoke to for our research also see a role for government in helping generate an evidence base that’s accessible to providers. This is particularly important where technologies may have been tested, but in a different national context.
Many respondents called for establishment of industry standards to protect against data and privacy threats, and the loss of jobs.
Finally, governments have a responsibility to ensure vulnerable people aren’t exploited or harmed by technologies. And they must also ensure robots don’t replace human care and lead to greater social isolation.
A few times a year the good people over at Power to Persuade turn over the blog to the Public Service Research Group for a week. Over that week we run a number of pieces based on work that we are doing across the group. In the recent PSRG week one of the pieces that ran was based on a chapter that I wrote with colleagues at PSRG on the development and recruitment of the public service workforce. This chapter comes from the book I was involved in editing on the future of the public service, published by Springer.
In this piece we delve into issues of development and recruitment employing a social learning framework. We outline four distinct elements to this approach that we argue can serve as a framework for building workforce capability and supporting change within the public service.
The piece can be found here and if you go to the site you can also find the other great pieces from PSRG colleagues.
In recent decades governments in industrialised nations worldwide have been embracing marketbased models for health and social care provision including the use of personalised budgets. The Australian National Disability Insurance Scheme (NDIS) which commenced full implementation in 2016 is an example of a personalised funding scheme which has involved substantial expansion of public funding in disability services. The scheme involves the creation of a competitive quasi market of publicly funded disability service providers who had previously been block funded and had historical practices of communication and collaborative working.
Research has shown that introducing or increasing competition can impact collaborative efforts between service providers. I am part of a team who have recently released a report based on qualitative interview data from disability service providers during the roll out of the NDIS to examine the effects of the introduction of a more competitive environment on collaborative working between providers who had historical relationships of working together. The data shows that while collaborative efforts were largely perceived to be continuing, there are signs of organisations shifting to more competitive relationships in the new quasi market. This shift has implications for care integration and care co-ordination, providing insight into how increasing competition between providers may affect care integration.
You can find the full report through the Centre for Social Impact here.
This is the era of the so called ‘sandwich generation’with busy professionals caring for children and ageing parents. Imagine being able to more effectively manage both sets of care relationships via a series of new technologies – and better look after yourself in the process. That’s the future being promoted by a number of startup tech firms at a recent showcase.
Here we saw tech that allows you to monitor your children via smart devices. Through this you can check out where they are, how they are performing in school, how much screen time they are consuming (and remotely cease this if you think it is too much). The next big consumer boom in the med tech space is predicted to be in genomic testing. So you will know just what to feed your children given your knowledge of their predispositions to certain conditions and intolerances. Your smart kitchen ensures that you are always fully stocked on necessities, by automatically ordering products you run out of.
When you have a few minutes in your day, you check in with your robot life coach to view your own vitals and see how you are tracking in relation to a number of your life goals. Maybe you even do this while moving around in your autonomous vehicle, which is safer than you personally driving the vehicle and frees you up to work on the move. Your home personal assistants even monitor your speech patterns to check for symptoms of depression or Parkinson’s.
All of this you can do safe in the knowledge that your parents are well and being constantly monitored via wearables or in-home robots. These will tell you if they should suffer a fall or if one of a number of pulse, blood oxygen or other readings indicate something of concern. If anything should cause worry you can be immediately connected to a healthcare professional who can also access your parent’s personal data and advise on courses of action – all supported by artificial intelligence.
Sounds pretty cool, right? There are huge number of companies emerging that are keen to support you to more effectively “manage” your personal and collective caring responsibilities. But what costs does this come at and are there aspects of this we should be concerned about?
These potential applications raise a number of important questions, many of which have ethical and moral dilemmas. How safe is this data that is being shared and who owns it? Blockchain is widely employed as a way of ensuring that this is kept and transmitted safely, but is this infallible? If your DNA is being profiled who are you happy being able to access this? Maybe you want your GP to see this, but what about your insurance company? What about researchers? With a big enough data we might be able to make some new breakthroughs in the health arena. So should we all consent to share our anonymised and aggregated data? The recent response to the My Health Record scheme suggests that many of us are wary about this.
Would knowledge of genomic predispositions make us behave more “rationally”? If you knew that you were more likely to develop heart disease would you eat more healthily? Conversely, if this wasn’t a worry for you would you then engage in more “risky” behaviours? If we know one thing for sure it is that people don’t always behave in ways that are predictable or considered the more ‘rational’ option.
Some of the companies we spoke with talked about offering incentives to individuals to share different aspects of their data in return for vouchers or discounts off other products and services. While this avoids a situation where individuals are not rewarded for the use of their data, it raises potential equity issues. Those most likely to respond to such incentives are likely to be those of lower socio-economic groups. Indeed, the Australian Human Rights Commission has recently raised a number of concerns relating to technology and their potential to enhance inequities.
Although the discourse around many of these technological developments is that they should make us more “safe”, there is already evidence that suggests reason for concern. Addiction to technology is a real concern for many, particularly in relation to younger children. China has uniquely set legislation addressing this after concerns about wellbeing and intense game play regarding on-line game Honour of Kings. The developer, Tencent, responded by limiting users to the amount of time they can spend on the game and at what times. Although welcome by some, this a blunt approach and does little to address our obsession with electronic devices more broadly.
A feeling of safety in many of the examples we came across typically also involved some significant surveillance, either via camera, by data or a combination. Although this might lead to some of us feeling more secure, for others this could come with concerns about issues of human rights. A recent story in the New York Times highlights the issues associated with the expansion of facial recognition software and surveillance in China and some significant concerns about this within the context of an authoritarian regime.
It is clear that there are some exciting developments to come in the technology space that will have a profound impact on our everyday lives. But these developments also bring with them a series of potential negative impacts and associated ethical and moral concerns. Although some of these developments are some way in the future, many of these exist in our everyday lives now. Yet, one of the issues we are coming across in our research into the use of robots in care services is that governments are not yet systematically having conversations in a widespread way about what these technologies mean in terms of the ways in which we design and deliver public services and some of the challenges that these raise. A failure to consider these issues will likely mean that the first time we ever really consider these issues is when some sort of incident arises, by which time it will be too late.
While there is much to be excited about in terms of the future of care services, there are some developments that should give us pause for thought. It is a future we need to prepare for to ensure that we get the type of care services we want and need.
This post contributed by Catherine Smith, Melbourne Graduate School of Education, University of Melbourne and Helen Dickinson, Public Service Research Group, University of New South Wales, Canberra.
In this post, Gemma Carey (@gemcarey), Helen Dickinson (@drhdickinson), Michael Fletcher and Daniel Reeders (@engagedpractx)examine the role of National Disability Insurance Scheme (NDIS) actuaries, describing their purpose in the scheme, the limitations in the ways they are used and the implications.A full account of their research can be found here.
Most of us are familiar with actuarial approaches, though we may not be aware of them. If you have house insurance, insure your car or have a job (where you are covered by work cover) the premiums you pay are based on actuarial modelling.
Actuaries and actuarial modelling are central to the operation of the National Disability Insurance Scheme (NDIS). Internationally, the way that actuaries are used within the NDIS is very unusual although it is something that has not been written about extensively. If you have heard about actuaries and the NDIS it is probably because the outsourcing of this function made the news, largely due to $2.3 million that is being paid out on this over 5 years.
In this piece we unpack this role, describing the function of actuaries in the scheme and the limitations in the ways in which we are using them.
The NDIS Act outlines that the Scheme Actuary is responsible for overseeing and ensuring the financial sustainability of the scheme. Official duties of the Actuary, are to assess: (i) the financial sustainability of the NDIS; (ii) risks to that sustainability; and (iii) on the basis of information held by the NDIA, any trends in provision of supports to people with disability, including (a) the causes of those risks and trends; and (b) estimates of future expenditure of the NDIS. However, the Act does not authorize public monitoring and evaluation of how well the scheme is meeting its goals of ensuring choice, control, and better outcomes for individuals.
Supports to be provided under the scheme are based on the principle of providing ‘necessary and reasonable care’. This implies that estimating future costs requires not only adequate data on life expectancy, but also the life-long impacts of factors such as the medical progression of disabilities, the impact of new technologies on what might be regarded as ‘reasonable’, and changes in family circumstances affecting the availability of informal care. There are inherent difficulties in operationalising ideas such as ‘reasonable and necessary care’, which are inherently fuzzy. Moreover, the NDIS Act authorizes expenditures only indirectly, as a necessary implication of a provision which requires that expenditures ‘represent value for money.’ This introduces a role for the Scheme Actuary into almost all aspects of the system, since pricing of services and planning personalized budgets all impact upon value for money.
How is evaluation of the scheme done?
Neither the Act nor the initial design outline provisions for meaningful and ongoing monitoring and evaluation of impact, whether against the policy objectives or the participants’ self-identified goals. As a result, ‘value for money’ can only be judged in terms of efficiency – units of service delivered rather than outcomes achieved.
To fulfil the mandate set out in the NDIS Act, scheme actuaries require complex and longitudinal data, particularly to ensure continuous monitoring. Serious questions remain over how these data are obtained and its quality, with a current lack of transparency around the monitoring framework being designed by the actuaries and implemented by the NDIA, an agency whose capacity has come under considerable scrutiny. The Productivity Commission report (the blueprint for the scheme) argued that actuarial modelling would also play an important role in evaluating specific services and interventions funded under the NDIS. How this has translated into practice is unknown, as a result of limited transparency with both the actuaries and the NDIA.
The scheme is overly-focused on costs
Normally, actuarial cost modelling of services works through estimating costs based on independent information about prices and expenditures. However, in the NDIS, actuaries set the prices of services and supports, and, to some degree, also make decisions regarding what services are to be provided to whom through the NDIA and planners. For example, the actuaries have advised planners to not be afraid to make large upfront investments in equipment. As noted in the rules for the scheme actuary, the role is to “monitor, assess, and report on consistency of resource allocation across regions, planners, disability type, and other groupings as appropriate”. This could potentially see them involved in planning in a much more hands-on way in the future
The actuarial modelling of NDIS performance focuses solely on costs. As the Productivity Commission notes: “Financial (or actuarial) models measure any discrepancies between expected and actual costs and outcomes, and the adequacy of revenues to meet projected costs over the long-term”. The models explain why such discrepancies may have occurred, and analyse their implications for the financial sustainability of the scheme and its objectives for achieving outcomes for people with disability (either in aggregate or in specific categories). By itself, this modelling is limited in its ability to measure personal wellbeing or social and economic outcomes. It also cannot assess whether participants’ goals are being met, or whether participants experience their choice and control as purely formal (i.e. I get to choose who provides the service) or substantive (i.e. I get to choose how the service is provided). For a more robust evaluation of wellbeing, outcomes, and goals – which is after all the fundamental objective of the NDIS – alternative methods are needed and as the NDIS Costs Report points out, is a more difficult task than measuring costs against cost expectations
To date, there is limited information on benefits to individuals and families, which means that it is not possible to conduct a proper cost-benefit analysis. The NDIA has developed and piloted what it calls the NDIS Short Form Outcomes Framework, which comprises 8 participant domains (including choice and control, daily activities, relationships, home environment, health and wellbeing and life-long learning) and five family carer domains (e.g. whether families have the support they need, whether they know their rights, if they can gain access to desired services). The short form questionnaire does not attempt to assess whether participants feel the services delivered contribute to achieving their stated personal goals, largely because personal goals are so diverse and the instruments being used are not able to measure this.
In other words, while packages in the NDIS are personalized, the measures for success of the scheme are not. The NDIS needs a proper monitoring and evaluation framework that goes beyond assessing costs if we are to understand its real impact on lives.