It is important to understand the difference
between corporate medicine and other health care systems. This page
attempts to explain, the development of different systems, some of
the principles underlying the different forms of health care and the
forces which are generated by them. It provides the background
information needed to evaluate the material on this www site.
C. THE LATE 20th CENTURY HEALTH CARE MARKETPLACE
D. THE 21st CENTURY - PRIVATE EQUITY IN HEALTH AND AGED CARE (Added 2007)
Historically medicine was provided by doctors, members of the community who fulfilled society's humanitarian commitment to the misfortunes of illness and aging in its members. Medicine had little impact on the course of illness and much of the care was comfort and support. The doctor provided care to all in need. The doctor, usually male charged fees based on the ability of his patients to pay. There was an unwritten social contract in which the doctor did not abuse his position. He remained comfortable but not wealthy. Society provided status and security.
To meet society's expectations professionalism and professional associations developed ethical traditions and forms of control based on principles established by Hippocrates over 2000 years ago. When the profession and society identified with this idealised model it worked.
These flimsy structures have controlled the profession and protected patients from misuse. Personal gain or advantage has been recognised as the primary threat from which ethical structures protected patients. When they received strong support from the community and when the profession identified with them then these structures have served us well. They have however bent before powerful forces. They are vulnerable to changed attitudes in society. This is particularly so when professional values lose their legitimacy.
Professionalism for example bent and
sometimes crumbled in Nazi Germany and also under apartheid in South
Africa. Changing social attitudes and a loss in legitimacy of
professional values has been a particular problem during the latter
part of the 20th century. The development of a marketplace culture,
strong market pressures on the clinical encounter, and the
denigration of professional points of view by economists, corporate
interests and politicians have wreaked havoc. This is particularly
apparent in the corporate marketplace and this www site describes the
consequences.
Hospitals and other services for the sick and
dying were established by charitable church and community groups. A
system where the wealthy were billed to support services to the poor
developed. This Samaritan system formed the backbone of medical
services in many countries and persisted in the USA. In most other
countries government took over the care of the poor. Charitable
institutions continued to provide services to those who could pay but
devoted profits from their hospitals to other community services.
During the 20th century medicine has had a much greater impact on survival and suffering. Medical error has become much more devastating for the patient. The complexity of modern health care makes human error both more common and more devastating for both patient and the doctor. This change has been accompanied by a massive increase in medical litigation. It has placed considerable pressure on the profession and encouraged costly preventive medicine. It has destroyed the traditional bonds of trust and trustworthiness.
The maintenance of professional standards and of professional oversight has become a difficult problem for the profession. The need to address these failures in care has challenged the traditional autonomy of each individual doctor. Resolving this problem is ongoing and it is one of the strongest reasons for an integrated health care system.
The need for professional cohesion and action
has never been greater but at the same time professionalism is under
attack by a marketplace belief system which sees it as
anticompetitive and self serving. Indeed in the marketplace context
it probably is.
The second change has been the increase in technology and in specialisation. This has resulted in steadily increasing costs. The older system of the rich paying for the poor was no longer sustainable. Government and private insurance both stepped in to fund medical services and a wide spectrum of different sorts of services resulted. Payment is increasingly made by groups which are only peripherally interested in the individual patient's personal welfare but which has a strong commercial interest in the care which all patients receive. Government wants value for money. Insurers want profit. In order to meet their objectives both intrude into the relationship between the doctor and the individual patient and between the profession and the community.
The principle of equity of care for rich and poor has been universally accepted but not realised in practice. At one end are the nationalised health services such as that which developed in Great Britain. At the other is full private insurance for the rich. Government has often taken responsibility for the care of the poor, sometimes applying a means test. Tiered systems with varying degrees on inequity have resulted.
Government systems extend from providing all care as in the UK, providing universal single payer insurance such as in Canada and Australia or to providing insurance or care only to particular groups as in the USA. No government has prohibited the right of patients to seek and pay for private care and to go to private hospitals. Canada has not allowed private for profit groups to access Medicare funds. In Australia patients are encouraged to take private insurance and go to private hospitals and Medicare payments are made for care but not accommodation. More recently corporations of all types have been encouraged to participate in a health care marketplace. Their prime interest is not in care but in exploiting the opportunities for profit in this new marketplace.
Across most of the developed world except the
USA the care of the poor has been taken from charitable institutions
and subsumed into government public payer or hospital systems.
Government has sometimes funded charitable groups to provide public
hospital services.
Government run national health systems have been characterised by underfunding, a cumbersome bureaucracy, and consequent alienation and loss of staff morale. Despite this they remain the most economical way of providing care and the most equitable method to ration scarce resources. They work well when properly funded.
The increasing legitimacy of extreme economic ideologies has brought governments which view all of society as a marketplace into power. The underlying assumption seems to be that because humans are competitive all human activity should be based on competition - primarily market competition. All other activities are seen as anticompetitive and exploitative. Individuals are inherently avaricious and desired outcomes can be achieved by devising competitive systems which fan and exploit their avarice. Anti-competitiveness has become a mortal sin.
The argument runs like this. Because health care spends money and employs staff it is an industry. Because it is an industry and market practices have been effective in some industries health care's problems will be resolved by turning it into a competitive marketplace. These arguments are not only flawed logic but they fly in the face of all that we have learned about medical practice and the vulnerability of the sick over the centuries.
Government have set in place laws and structures such as Australia's National Competition Council (NCC). They seek to enforce market principles and competition policy on all sectors of society. They have used economic remedies to address the problems created by rising costs without regard to the human consequences. National Health Systems such as those in the United Kingdom and New Zealand have been reorganised to introduce market and competition pressures. Managers have been brought in from the marketplace. There has been an increasing move to contract services and even the care of patients to private commercial enterprises whose only interest in them is their commercial potential. Economic levers, supplemented by regulations and policing are relied on to protect the vulnerable. It is hardly surprising that they have failed to do so.
In New Zealand these practices have disadvantaged the poor and have alienated the entire community. They were an important factor in the elections. Government has since promised to replace competition with cooperation.
In Canada and Australia the public has
continued to support their single payer Medicare systems strongly.
Governments adopting economic rationalist theories have sought to
destabilise the public sector and drive citizens into private systems
of care. They have underfunded public systems and eroded the Medicare
system. In Australia they have even offered citizens an expensive
bribe to enter the private system claiming that this would take
pressure off public hospitals. This money would have secured more
care for more citizens in the public sector. Despite this agenda
politicians have continued to pay lip service to the humanitarian
ideas about equity which underpin the Medicare system. It is a worry
that they believe this themselves.
GOVERNMENT AND THEORY :: Health care in a broader context
Overarching all embracing theories about society such as economic rationalism, fascism, communism, and capitalism have been the scourge of the 20th century - the modern era. Millions have died in the service of these systems of thinking.
The postmodern thinking of the younger generation as expounded by Chan and Chan challenges these grand ideas1. Instead of embracing theory and all encompassing views it lays stress on "the small narrative based on lived lives, the diverse, the complex and the unique". It seeks to understand the limits of theory.
The young writer Hsu-Ming Teo also emphasises the individuality of lived experience and understanding.2 In looking to the 21st century she was not optimistic. In speaking of the grandiose all encompassing ideas of the modern era and the havoc they have created she stressed that there was "no real break with the 20th century. The tides of continuity wash over and litter the future with the debris of the past." This is not to challenge the insights of broad theories but to recognise their limits and dangers.
Currently political process is geared to simplistic theoretical answers to complex problems. Until the present older generation of leaders die off we will have to live with all encompassing theories of economy, markets, society, quality and of science - the debris of the 20th century. They will remain the only credible way of understanding the world. We will not understand the limits of theory and we will continue to squeeze all of life into simplistic and distorting frames of understanding. The immediate future is bleak and the intellectual battle has hardly been joined.
In essence the modern conflict lies on the one hand between a concentration on measurable outcomes, usually economic, with the emphasis on incentives and penalties in accomplishing these. They are the endpoints. This is essentially a behaviorist model of humanity built on the responses of rats. Human animals respond similarly. It takes no account of human cognitive processes and wider consequences provided specific outcomes are achieved.
This web site takes the alternative cognitive point of view. It sees the ideas which we develop in the situations in which we find ourselves as the focus through which we act in order to build our lives. It is the lives we live and the societies we build which are the end points.
In education we long ago learned that behaviourist methods produced objective outcomes but did not produce educated individuals. There were many undesirable side effects. Almost all educators now follow cognitive approaches to teaching.
Society has not yet learned that while behaviourism, particularly economic behaviourism may very successfully produce measurable outcomes it cannot create a livable human society. All too frequently pressures used to attain the measured objectives result in the development of systems of thinking which are severely destructive for society.
The issue goes to the question of what we as individuals and society as a whole are all about. If we are about economic objectives and enslaving all of society in competing to attain these objectives then we are going the right way.
If we are about building a complex society and a world in which we can all live and realise our varied potentials and individual lives cooperatively then we are going in the wrong direction. The evidence that this is so is now in. Health care is one of the best examples of this. I came to these issues through failures in health care consequent on this approach. These pages provide an insight into these issues through the medium of health care.
The argument is that the former results oriented economic belief system is not built on a sound footing. It misrepresents the human condition and is consequently unstable and at risk of collapse. Even its success depends on the transient ascendency of some and the failure of others. The broader cognitive approach is slower and more laborious but ultimately sustainable.
Economic well-being is the basis for our western society. It makes it possible. It is not the reason for society or for our existence but in becoming this it threatens to destroy the humanity which is the very essence of our existence.
1. Chan J.J and Chan J.E. "Medicine for the millennium: the challenge of postmodernism" Medical Journal of Australia 3 Apr 2000; 172:332-4
2. Hsu-Ming Teo "Those who can, do" The
Australian 1 Jan 2000 p 30
THE DEVELOPMENT OF FOR PROFIT MEDICINE
In most countries including the USA and Australia private hospital services were set up by church and community charitable groups. With the advent of government insurance schemes, such as Medicare in both countries sectors of the business community have seen the potential for massive profits in health care. These systems, unlike that in Canada did not discriminate in who were paid for providing services. The ideology of individual rights dictated that all could do so. Large market listed companies seized the opportunity. They have come to dominate health and aged care in the USA and are growing rapidly in Australia. Were it not for the events described in these web pages the Australian health system would already be dominated and controlled by large multinational health care corporations.
Profits from unsubsidised private insurance and from payment by individuals is limited. The potential for large profits lies primarily in access to government funding either through Medicare payments, by government support for private insurance, or by contracting corporate interests to provide hospital care to public patients. This policy of contracting public hospital services to corporate interests was a policy of the Australian federal government. It was embraced by Australian states with conservative governments. It was these contracts which interested multinationals.
The privatisation experiment failed and hopefully has now been abandoned. Australia is now less attractive to multinationals and their conduct in the USA has made them unacceptable to Australian citizens. They are constrained by our probity regulations. Instead government is supporting Australian corporations under the illusion that they will behave differently under similar pressures.
US Multinationals have enlisted the support of the US government in pressing for international trade agreements which would open all government sources of profit to multinational corporations and remove impediments to "legitimate business" like our probity provisions. It is important to understand that it is not private insurance or individual payment which forms the backbone of the corporate for profit health system but taxpayers money dispensed through Medicare and by government contracts.
A short account of the development of corporate medicine in the USA is described in a paper I presented at a meeting in 1996.
CLICK HERE -- to link to relevant section of the paper
Contrary to political rhetoric and public perception the critical issue for health care is not how we pay for it but for whose benefit we provide it. One way or another we are going to raise some money. The social objective will be to stretch it to fund as much care as we can. There will always be limits on this. Do we provide it for the benefit of the sick and the communities in which they live (not for profit care) or do we provide it for the benefit of shareholders or others with similar profit motives (for profit care).
At the turn of the century only the USA has a dominant competitive corporate health care marketplace which has been in existence for a reasonably long period of time. In his speech to the World Bank in February 2000 Graeme Samuel, chairman of Australia's National Competition Council set out a model for a health system built on economic marketplace theory. While he is careful to understate this, it is clear from Samuel's speech that he sees large publicly traded groups as the primary vehicle for implementing the strategies which he proposes. Incredibly he was advocating this for the rest of the world.
Experience in the USA shows that in a competitive corporate marketplace community focussed church and charitable not for profit groups are less able to compete and ultimately sell or else merge as "joint ventures" with for profit publicly traded groups. This allows the for profit group to maintain the illusion that they are providing a primarily community and humanitarian service while milking it for profit. This is now happening in Australia with a large not for profit community health system in South Australia selling to a for profit group in 2003.
In Australia out of hospital services are paid for by government on an item of service basis. The patient sometimes making a variable copayment. The Australian hospital system is divided on the extent to which Medicare, the patient or insurer pays for private care, or whether government pays and provides the entire service in a publicly owned hospital.
Because our private system has been dominated by not for profit religious and community groups the service which they provide is what we have considered to be private care. In Australia and to a lesser extent in the USA corporate groups have entered what has now been reclassified as a "marketplace" under the umbrella of this charitable system and the values which it espouses.
We should clearly understand the difference
between these two systems. Advocates of market theory fail to
confront cognitive factors or the motives which result from them.
There are fundamental differences in the way people in the two
systems see their roles and their motives.
These are church and community groups founded to serve the needs of the community. They embrace the ethical traditions of the health care professions, the values of their religious orders and the Samaritan traditions of our society. Their primary commitment is to the welfare of the patient and to the community. There are few extraneous pressures away from care. When profits are made they are ploughed back into the community in those areas of need which would not otherwise receive funding. The patterns of thinking generated in the system serve its objectives and are essentially functional for the community.
We should understand the difficulties which
not for profit organisations have in competing in a marketplace where
the value systems on which their legitimacy depends are meaningless.
There are strong pressures to sell out to those who identify with the
new system.
With few exceptions these were either founded in order to make a profit out of health care or else entered health care diverting from other activities because the opportunities for profit were greater. Profits are made by charging more and by keeping costs down. The major cost of the system is care and particularly the staff who provide this care. At the centre of the for profit system is a strong conflict of interest between profit and care. They both compete for the available health care dollar. The more care is restricted the greater the profit.
As a consequence the patterns of thought
developed place profits first and individuals reach their potential
by making profits. In order to maintain this in the face of community
and politically correct perspectives they must employ a number of
psychological and logically suspect rationalisations in order to
persuade themselves and the community that what they are doing is
putting the patient first. Profit and care they claim go together. If
care were compromised then they would not be making a profit. This is
"marketthink". Cognitive processes are distorted and we get
unanticipated adverse outcomes.
PAYMENT SYSTEMS - ITEM OF SERVICE
In an item of service system, where the provider sets the fee the problems in care are less acute. Fees are increased to cover service and profit. In not for profit services ethical systems have generally withstood the pressures to misuse patients for profit. The ethic to provide the best possible and "do all I can" for the patient pushes up costs in all systems. A system where the provider sets the item of service fees and does all she can to provide a service results in cost blow outs quite independently of pressures to increase profits.
A strong emphasis on profits generates even
more over-servicing. It breeds systems of thinking which make it
legitimate to misuse the sick for profit. This has occurred
particularly in those under most pressure to generate profits - the
for profit corporate systems. Corporate groups have not hesitated to
exploit the most vulnerable sectors of society to increase profits
and create vast empires. This is particularly so in the USA. In
Australia Mayne Nickless was accused of cherry picking healthy
patients and turning away the costly unwell, a common manifestation
of this process.
PAYMENT SYSTEMS - CAPPED PAYMENTS
Patient care dilemmas occur principally in
systems which cap fees or payments by regulation or by pressures
generated in the market - such as managed care. Insurers in Australia
cap fees in this way negotiating discounts from competing hospitals.
Not for profit systems are able to respond by stretching the
resources as far as they can and a form of concerned and humanitarian
rationing should occur. For profit systems have to resolve the
interests of the patient against the profit interest of the provider
-- whether the provider is an individual, a private company or a
listed company. As the marketplace provider's survival depends on
profit, the interests of the provider wins out every time. Sadly many
not for profit providers have health care have learned that their
survival in a competitive marketplace depends on embracing the same
marketplace thinking and practices.
Systems which cap fees do so in order to contain costs and reduce the money spent on care. A minimum amount is paid. The profits generated are consequently a question of conscience - the extent to which the provider of care takes money out of care for profit and compromises care as a result. Much will depend on the pressures for profit and on the sort of people providing care - as we will see, on this www site on their psychological make up. This cultural and psychological aspect is best encompassed by the word "probity" -- the old worldly idea of being a "fit and proper" person - someone who will behave responsibly in dealing with society even under pressure.
An important consideration is the extent to which market ideology and culture has generated patterns of thought which have encouraged those providing care to circumvent the pressures of conscience. In studying the market we need to look at the way market ideology and a strongly competitive marketplace have made it legitimate for excessive profit to be taken at the expense of the care of patients? Participants in a marketplace believe that they have a right to take profits from the system. This is why they are there. Their patterns of thinking make it socially acceptable to take profits away from the care of people in need and people unable to care from themselves, when as we are repeatedly told resources are limited and rationing is required?
There is a separate page reflecting on probity
It is also necessary to distinguish between for profit companies owned by individuals and those traded on the share market. Directors and managers of companies traded on the share market have a primary fiduciary duty to shareholders. This primary duty is to protect their interests and to make as much money as possible. They have no responsibility to patients and there is no more responsibility to provide care than there is for a second hand car salesman to sell a mechanically sound car.
In the past some protection has been provided in Australia by the public expectation that the providers of health care will be "fit and proper" people - people who can be trusted. This expectation is given formal recognition in licensing regulations. This is not a requirement for selling cars.
The success of publicly traded companies is closely linked to their share price and this depends on demonstrated profit and growth. There are acute and ongoing pressures to generate profits. Any decline in profits or in indicators of future profits is noted by analysts and rapidly reflected in share prices.
A system of incentives and bonuses ensures that directors and managers understand the financial priorities. They are rewarded on the basis of profits generated. There are few rewards for providing care. The costs of being caught providing substandard care are minimal.
The future of the company and its directors depends on profits. The stronger the competition in the marketplace the more do short term considerations dominate over potential long term problems. They are happy to survive to meet them. Poor performing companies are targets for takeover and then restructured to improve profits. The existence of a company depends on keeping profits up all the time.
Probity is consequently under far greater pressure in market traded companies. Shareholders are not concerned with probity issues unless they have financial implications.
In publicly listed companies a vast amount of money, thought, human effort and time is devoted to competition and to market based activities. This is at the expense of the money effort and time devoted to care. Our human capabilities are limited. They can't serve two such demanding masters without cheating on one, In practice a culture develops in which profit dominates decisions.
Another considerations is the extent to which profits are ploughed back into the community. Some profits very probably will be reinvested but only if this reinvestment will yield more profits for distant shareholders. It is unlikely to go to those in need.
Clearly we should all challenge Wall Street
is an appropriate environment from which to address not only the care
versus profit conscience problem but the many ethical problems which
constantly arise in health care - including rationing of organs and
other scarce resources.
Many corporate executives and staff do embrace a mission of care and genuinely believe that the market is the way to address problems in health care and provide care. They angrily reject my analysis and set out to provide good care. Unfortunately they do not have the power to do so.
The ultimate power lies with the institutional funders, the pension and superannuation funds, managed funds and the banks which advise and act as a conduit for market forces. They hold the vast majority of shares and loans. Their sole responsibility is to provide returns for those citizens whose money they control. They have no interest in health care or citizens other than returns. They have the power to appoint and fire senior executives who do not follow well recognised and approved market strategies.
Institution investors and lenders can dictate policy, dismember or sell the company, or put it out of business. Their survival also depends on the profits they develop for their customers. They are ruthless in this. Ordinary citizens have no idea what is being done on their behalf. Mayne Nickless is a good example of how this works.
Executives who try to spend resources on care do not survive once the market becomes strongly competitive. Those who are able to persuade themselves that this is what they are doing do well.
The large financial institutions play a major role as advisors and as mediators of market pressures. They advise on mergers and takeovers and much of the pressures are exerted in this way. Companies and senior staff who do not conform will be taken over or fired. Citigroup is a good example of this.
These companies are usually run by a single person or a small group. While they clearly have to make a profit to survive, the pressures are much less and certainly much less acute. Profit now can be deferred for profit later. The way in which the care versus profit conscience problem is met will depend much more on the sort of people owning the corporation - whether their motives in investing their personal wealth in care were entirely for profit or whether they were motivated by humanitarian of public spirited factors. The services provided consequently cover a wide spectrum from the best to the worst. Strict enforcement of probity requirements help to weed out the worst.
Like old time shopkeepers some were part of the community and saw themselves as serving the needs of the community rather than simply competing for profit. Interestingly Markalinga in Western Australia started as a company like this. When it collapsed it was bought by the US group National Medical Enterprises (NME). One of the early investors later wrote to praise my efforts in forcing this company out of Australia.
Ramsay Healthcare in Australia has until
recently been privately owned. My information is that it has behaved
more responsibly. Mayne
Nickless' HCoA, and Sun
Healthcare's Alpha Healthcare were
market listed companies in Australia.
THE CUSTOMER IN CAPPED SYSTEMS
Market advocates claim that the 'customer' exerts market pressures to prevent the provider from taking out excess profit and a balance is struck which protects the customer. Clearly where this balance is struck will depend of the strength of the opposing forces. The question then arises as to whether the health care customer does or is capable of actually exerting pressure in the situation in which she finds herself.
In the publicly funded but corporate run hospital systems favoured in Australia in the 1990s it is actually the government which pays. The contracting of public hospital care did not work and was abandoned. I have become aware of pointers which suggest that the market and the political right may be thinking about this again.
The customer's role is at arms length and exerted indirectly via government. The way in which governments have fulfilled their responsibilities in situations similar to that suggested by Samuel must be examined.
Medicare and Medicaid are the funding systems which form the backbone of private medicine for the less privileged in the USA. Both are funded by the tax payer. US Medicare patients do however exert more choice and so pressure than in the Australian public hospital system.
Insurers enter into contracts with hospitals for the provision of services - in effect a capped system for private care. In all of these systems the funding and so the care given is determined by 3rd parties, sometimes after aggressive behind closed doors haggling - parties seeking to take as much from what they get for profits as they can.
Government oversight processes have failed in the USA and in Australia. Several pages on this site address the failure of regulation and various forms of oversight. You can follow the links on the following pages to reach other pages.
Government Oversight, Regulation and Surveillance
The Accreditation and Complaint Processes : Australian Nursing Homes
Private equity, the purchase of companies by financiers was once known as Venture Capital. They funded the development of research into commercial enterprises. This was high risk investment with a high return when successful. Venture Capitalists have changed rapidly during the 21st century. The first step was the purchase of failed or failing companies. The financiers moved their financial managers into the company, imposed their commercial solutions and having made the company profitable sold it. The companies are taken off the sharemarket and are consequently less subject to regulation and scrutiny. They are not subject to the ongoing month by month demand for profits by shareholders but ultimately they aim to make even bigger profits. Their object is to make money by market processes including cost cutting and management reorganisation. They make their profits when they sell of float the now profitable companies again. I some instances it is more profitable to strip the companuy of assets and then sell what is left.
These private equity buyouts have become larger and larger and have targeted any company where the financiers feel that they can make it more profitable by taking it off the sharemarket and applying their business skills. In the USA the largest hospital (eg. HCA and Triad) and nursing home (Beverly and Mariner) operators have been acquired by private equity groups.
Australia has been part of the massive growth in private equity with several large companies falling victim. Citigroups Asian Venture Capitalist entity CVC Asia Pacific purchased Australia's largest hospital group (Mayne Hospitals) in 2002 and our largest nursing home company (DCA) in 2006.
Private equity increasingly dominates the marketplace in the USA and Australia. It moves the decision making process away from the particular domain of activity in which the company is involved and places it in the hands of financial managers applying global business strategies.
Instead of being run by managers who are part of the community and being owned by local shareholders ownership and managment shifts to global entities distant from the community that is served. This has major implications for vulnerable sectors like health and aged care. Many of the global financiers involved in private equity have very poor track records for defrauding and misusing those who trust them and whom they claim to serve.
In 2007 some Australian senators became concerned about the economic consequences of the explosion in private equity. An Australian senate inquiry examined the issues and reported in August 2007. I made a submission to this committee stressing the consequences of the phenomenon for the Australian community, particularly in health and aged care. Marie dela Rama from UTS also made a submission. The report discounted our concerns and in essence supported this development.
The USA is 2-3 years further down this path. In September 2007 only weeks after the Australian Senate report the New York Times reported a wide ranging study showing a rapid deterioration of care in nursing homes acquired by private equity. It described how the financiers had conspired to prevent families from claiming damages for negligence- the only effective restraint in the USA - by creating complex market sructures. This has become a major political issue. Senator Hillary Clinton, a likely Democratis party presidential candidate, and Representative Grassley, a senior Republican are both calling for a congressional review and action. The validity of our submissions has been confirmed.
Click Here to dowload my (Michael Wynne) submission to the senate. (659KB pdf file)
Click Here to dowload Marie dela Rama's (UTS Centre for Corporate Governance) submission to the senate. (206KB pdf file)
Click Here for information about the New York Times study (Link to Aged Care Crisis Centre)
Click Here to go to a page describing investment by banks and other financiers in Australian aged care.