Data released recently by the Australian Institute of Health and Welfare shows the nation’s health care bill is rising rapidly, from $77.5 billion in 2000-2001 to $130 billion in 2010-11. The largest increases were in public hospital services and medicines, prompting questions of how we can rein in these costs.
The fact that Australia’s health spend is growing isn’t surprising – our medical services are offered under an uncapped fee-for-service system of funding, which favours activity rather than prevention. In other words, funding is skewed towards offering procedures rather than advice.
Australians have for many years relied on a “specialist”-driven health system, where patients are encouraged to seek advice from specialist clinicians rather than rely on the opinions of dedicated general practitioners (GPs) and general physicians.
Specialists are remunerated at a higher rate and are often deemed better at providing medical advice. But this isn’t necessarily the case, particularly considering the growing prevalence of chronic diseases – such as diabetes, heart disease, cancer, arthritis, asthma and mental health problems – of which 80% of the elderly population have three or more.
With chronic diseases and ageing now setting the health-care agenda, we require a different approach to care. After all, is it really rational to expect patients who have multiple chronic diseases to see a different specialist for each one? In most cases, a well-trained generalist (GP or general physician) can care for these patients and have just as good – if not better – patient outcomes.
This thesis was argued recently by Professor Richard Murray, President of the Australian College of Rural and Remote Medicine, in an opinion piece for the Weekend Australian. Not only would generalists provide much more cost-effective care to those with chronic disease, he said, they could also provide care across the country in rural and remote areas.
Rather than clinicians working alone, this new model is based on the profession(s) working as a team to improve patient care, with an eye on the cost of that care. Telemedicine (video conferencing) and other technologies allow specialists in regional centres or capital cities to communicate with rural and remote health providers.
Mid-level health providers
Let’s push care of chronic disease even further. Do you always need a doctor in the front line? Or would you be happy to see a nurse practitioner? Or a relatively new type of health professional, a physician assistant?
Health Workforce Australia (HWA), the peak body on health workforce issues, recently acknowledged such mid-level health providers as a much-needed addition to Australia’s health workforce. It noted PAs were well-trained professionals who could manage much of chronic disease care of patients, working closely with doctors. Concluding that PAs provided very good care to larger number of patients, HWA noted these new providers helped to reduce waiting lists and allowed the health care dollar to go further.
But there are only a handful of PAs in Australia. The University of Queensland’s now-suspended program only graduated around 40, though most of these are employed in defence health or in the private sector. Nurse practitioners are also underutilised and could do many tasks that are currently performed by other practitioners.
So why are so few nurse practitioners and physician assistants in Australia?
Resistance from the health professional organisations, the unions (Australian Nursing Federation and the Australian Medical Association), which want to protect their profession’s turf is likely to have played a role. It’s also partly the result of the inherent conservatism of the siloed health professions.
Reining in costs
We have a great health-care system in Australia but it will soon become financially unsustainable.
Already out-of-pocket expenses (the difference between what the doctor charges and what the patient gets back from Medicare and/or the health fund) as a share of total health-care costs are higher than the median for developed countries. And they’re rising.
We have a Rolls Royce system of health care in Australia. Trouble is, it’s unaffordable in the long term and many patients may only need a Mazda.
We need to get serious about prevention and keeping folk out of hospital, about primary care, about teams rather than individuals, and about the sensible use of technology to drive workforce productivity. Otherwise, we’re going to find it harder and harder to provide equity and access to quality health care for all Australians – let alone those with chronic disease.
The evidence shows it’s time for Australia to build a strong mid-level health workforce that works with doctors, nurses, allied health professionals and others to focus on patient needs and patient and community health outcomes.