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Next steps in health care reform

Australia is facing an epidemic of chronic lifestyle-related diseases, including type 2 diabetes, heart disease, stroke and chronic lung disease. We have many treatments for these that aren’t necessarily…

The poor suffer the greatest burden of disease but are less able to deal with the costs. Brooks Elliott

Australia is facing an epidemic of chronic lifestyle-related diseases, including type 2 diabetes, heart disease, stroke and chronic lung disease. We have many treatments for these that aren’t necessarily curative but are highly effective at maintaining health and prolonging life. But some Australians miss out due to cost.

Australians have access to universal health care, but governments don’t cover all the costs. Out-of-pocket expenses comprise approximately 18% of health spending in Australia - higher than the OECD median of 15.8% and higher than in Canada, New Zealand or the United States.

These costs impact directly on patients and their families. A recent Australian Bureau of Statistics survey found 9% of adults delayed or failed to fill their prescription over the preceding year because they couldn’t afford the cost. This percentage rose to over 12% in the most socioeconomically disadvantaged fifth of the population.

The same survey found that 10% of adults referred to a medical specialist delayed or didn’t keep the appointment because of cost.

You’d expect those who are most in need to receive the highest proportion of subsidies. But this isn’t the case. Less than 4% of benefits from the Extended Medicare Safety Net are distributed to the 20% of the population living in Australia’s poorest areas. In contrast, the 20% living in the most affluent areas receive over 50% of benefits.

This is a disgrace: the poor suffer the greatest burden of disease but face the greatest cost barriers to health care while receiving the least assistance. And the tinkering in the May budget will do little to address these inequities.

Primary care reform

Abundant international evidence shows that high quality primary care, supported by other specialist medical, nursing and allied health care, can reduce the risks of chronic disease and its complications. The final report of the National Health and Hospital Reform Commission (NHHRC) drew on a wide evidence base in recommending strategies to encourage patients at risk of chronic disease to voluntarily enrol with a primary health care provider as their “health care home”.

But the Commonwealth government has not implemented this recommendation. Instead, it is investing many millions of dollars in the Personally Controlled Electronic Health Record. This e-health infrastructure will assist in communication between providers but will not necessarily improve coordination of care, and raises significant concerns about quality and safety.

What would a health care home look like?

There are already excellent general practices in Australia that include doctors, nurses and allied health staff (such as psychologists, physiotherapists and dietitians) working together, cross-referring and providing a one-stop shop for patients.

Many community-controlled Indigenous health services have developed a similar model of comprehensive multi-disciplinary primary care, which brings benefits of accessibility to multiple health disciplines, rapid communication between providers and coordination of their care. For smaller practices, close working relationships with local community and allied health professionals can bring similar benefits.

Flickr/401(K)2012

But the current Medicare schedule, which lists the government rebates for medical services, does little to encourage multi-disciplinary care. Many item descriptors require the service to be provided by a doctor, even if another health professional could do as good a job, or better.

A further recommendation of the NHHRC was the introduction of Medicare payments to reward a clinic for good outcomes for their enrolled patients, such as quality and timeliness of care. But again, this recommendation has been ignored.

Revising primary health care financing to encourage voluntary enrolment and team care would go a long way to foster the transformation of private general practices to one-stop, comprehensive multi-disciplinary services. Most importantly, it would improve the quality of patient care.

If I suffer a stroke or appendicitis, then I want to be treated in hospital. But if I have a chronic condition such as diabetes or asthma, then I want a collaborative relationship with a general practitioner and other members of an integrated, multi-disciplinary primary health care team I know and trust: a team with ongoing responsibility for treating my illness, assessing my risks, reducing the likelihood of complications, and acting quickly and effectively if there are problems.

What’s next for health reform?

Australians enjoy better-than-average life expectancy, high quality health services and below-average expenditure on health care. But these averages mask deep inequities. Many people in this country are unable to afford the care they need. The poor, Indigenous Australians, some immigrant and ethnic groups, and those living in rural and remote areas are particularly disadvantaged. This is unacceptable for a rich country with a relatively buoyant economy.

Canberra has made an impressive start by restructuring primary health care through the establishment of Medicare Locals. But as the Council of Australian Governments continues to pursue its health reform agenda, the challenge now is to ensure equitable access to high quality, integrated health care for all.