The architect of Australia’s aged care classification system has told a Senate inquiry the Support at Home algorithm cannot be fixed by tinkering – and questioned whether the rules underpinning it are even lawful.
The algorithm determining Support at Home funding is “fatally flawed”, incompatible with the recommendations of the Aged Care Royal Commission and potentially in defiance of the new Aged Care Act, Professor Kathy Eagar has told a Senate inquiry.
Giving evidence to the Senate Community Affairs References Committee this evening, Professor Eagar said the fundamental problem with the Integrated Assessment Tool (IAT) algorithm occurred at the first branch of its decision tree and could not be repaired by adjustments further down.
“My conclusion is obvious: the algorithm is fatally flawed, and its continued use can’t be justified,” she said.
Professor Eagar, who led the development of the Australian National Aged Care Classification used to fund residential aged care, demonstrated how a one-point difference on the IAT’s 48-point functional scale could produce a $40,000 difference in annual Support at Home funding.
In one example, two people with otherwise identical needs and compounding factors but functional scores of 24 and 25 were allocated to funding levels eight and five respectively – a 51% difference in funding.
“The first branch of the tree is a really bad and, in fact, indefensible way to create an algorithm,” she said.
Professor Eagar said the 23 items used to produce the functional score at the top of the algorithm did not include dementia and other cognitive impairments, mental health issues, unpredictable behaviours requiring supervision, elder abuse, social and environmental issues or carer issues.
“It is unbelievable for me that we can have a system that does not take those items into account right at the top in determining what branch of the tree you get into,” she said.
Those factors appeared later in the decision tree, but by then had only a marginal effect on the ultimate classification.
“If that branch is wrong, then the whole thing is completely wrong,” Professor Eagar said.
She also said the algorithm had been substantially changed “very quietly” in July this year, when 13 of the 33 items previously used to calculate the functional score were removed and three introduced.
“There’s been a lot of contentious disagreement about whether the algorithm was ever validated. In my view, it never was,” Professor Eagar said.
“But even if it was, the algorithm has now changed so substantially in July that the version that is now the national rule has certainly not been validated.”
‘Real legal question’
Professor Eagar went further when questioned by Opposition health and aged care spokeswoman Senator Anne Ruston about whether the system was consistent with the Royal Commission’s recommendation for needs-based aged care.
“I don’t think it’s compatible at all with what the Royal Commission recommended, and I also don’t think it’s compatible with the Act,” Professor Eagar said.
“And in fact, I think there is a real legal question – I’m not a lawyer, but I think there is a question that our legal experts need to question – are the rules actually in defiance of the Act, because I personally believe that the rules are illegal and are not consistent with the Act.”
Professor Eagar argued Support at Home had reversed the usual sequence of assessment, care planning and funding.
Instead, the IAT assessment now led to an algorithmically determined financial entitlement, after which care planning was based on what the person could afford.
She said redefining aged care in this way as a financial entitlement was “not compatible with the new Aged Care Act”.
Rae: rapid review underway
Earlier today, federal aged care and seniors minister Sam Rae defended the IAT and pointed to a rapid review of its prioritisation mechanism, which he said was expected to report within the next month.
Asked by Health Services Daily how much more evidence the government needed before deciding whether to abolish, reset or further adjust the algorithm, Mr Rae said the IAT was intended to deliver fairer and more efficient outcomes.
HSD then asked Mr Rae why the government would not scrap the algorithm and start again if Professor Eagar demonstrated it was fundamentally flawed.
“Well, I’ll leave it for the commentators to commentate,” Mr Rae said.
He pointed again to the rapid review and to work on an escalation pathway for people whose needs were not accurately reflected through the IAT.
But Professor Eagar told the Senate inquiry tonight that changing the priority system would not address the underlying problem.
“If the purpose is to give people the wrong funding faster, then that’s a good idea to do that,” she said.
Professor Eagar said a competent group of clinicians could design a priority rating system in 72 hours, but that would not address “the fact that the funding people ultimately get is not right”.
Senator Ruston had made much the same argument to HSD before Professor Eagar’s evidence.
“It continues to amaze me that, despite all of the evidence that has come out through various means, not the least of which [was] Four Corners, that the minister is still belligerently saying that he’s doing a rapid review of the priority allocation,” she told HSD this afternoon following her speech to the CHSP national conference in Melbourne today.
“That means you’re doing a rapid review of something that’s broken, so basically you’re just going to get to your problem more quickly.”
Senator Ruston said that unless the government addressed the algorithm’s “fundamental flaws”, changes further down the process were “completely pointless”.
No international precedent
Professor Eagar told the committee she knew of no country using an algorithm of this kind to determine a person’s overall aged care budget.
“There are some countries that use algorithms for a specific service type, like do you need cleaning, but not in terms of a holistic person budget,” she said.
“Many countries have tried it, and they’ve all abandoned it.
“It does not work because no one tool, no one algorithm, can be all things to all people.”
Professor Eagar called for the “whole front end of community aged care” to be redesigned.
Until that happened, she said the government had an ethical obligation to restore assessor override, allowing expert assessors to override the IAT and use specialist assessment tools where necessary.
“What is happening now is actually unethical,” she said.
“It’s causing such hardship and distress that nobody can stay quiet on this issue. It is really unconscionable that this continues.”
Professor Eagar also argued people seeking straightforward CHSP services should not have to undergo the full IAT assessment, and should instead be referred directly to the services they need.
The committee is due to report to the Senate on 24 November.