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First published: Tuesday, December 31, 2013

Making patients pay out-of-pocket for visits to the doctor is cruel and discriminatory, having most effect on the disadvantaged, writes Tim Woodruff.

A proposal being considered by the Abbott Government to introduce copayments for GP visits is economically dumb in addition to being heartless.

The stated aim of such copayments is to save money and to stop overuse so that there is more money for those who need care. But the likely success of such a proposal is highly questionable.

There is little doubt that such copayments would reduce GP visits and thus reduce the cost of rebates to GPs. But some of that reduction would be for visits to the doctor that are very appropriate.

Imagine a single mum with three young children, all of whom have asthma. One is unwell so she attends the GP: $5. Day two, and another one is unwell, and the first is no better: $10. Day three, the third has the same symptoms and the others are unchanged, so she looks at the wallet for $15. She’s short on money as the fridge broke down last week and cost $150. She hopes things will settle. Night-time, and her third child gets worse, gasping. What follows is fear, an ambulance trip, an emergency admission overnight, and taxpayers paying $1,000+ for the treatment.

Imagine the young man with a mental illness, who is depressed, unemployed, and on medication but not taking it regularly. He gets desperate, considers seeing a GP, but is broke. He postpones the visit. He drifts into psychosis, and is taken to emergency. Where is the cost saving?

Then there are all the patients who we encourage to be screened for diabetes, blood pressure, and cancer. They see the ads, reluctantly think perhaps they should get screened, and are then confronted by a copayment.

It is dumb policy.

Of course, the copayment could be introduced in a variety of ways. It might just target those who don’t have a pension or health care card. It might allow a dozen visits bulk-billed and then charge, or charge a copayment for the first dozen visits and then stop, much like the Pharmaceutical Benefits Scheme.

One might argue that those not on a health care card can easily afford a copayment. The theory might be correct, but then there is reality. Low wage earners just above eligibility for pensions have to budget for everything, sometimes paying other out-of-pocket costs for a sick spouse who can’t get a pension because there is a wage earner in the family. The single-mum mentioned above could be working, earning just enough not to qualify for a pension, as well as supporting a sick unemployable husband and the three kids. Money is short. Another excuse to put off the Pap smear to pick her cervical cancer early, and so taxpayers bear the cost of her completely preventable cancer treatment.

The Pharmaceutical Benefits Scheme (PBS) has copayments of $5.90 for pensioners and health care card holders and $36.10 for the rest, and there is a safety net which cuts in after a certain amount is spent. Thus patients must find the money early in the year or go without. For years the Commonwealth Fund has demonstrated that about 20 per cent of Australians avoid filling out prescriptions because of costs. All doctors know that getting patients to take their medication appropriately is a constant challenge. But the Government puts a barrier in our way. Copayments for GP visits will have the same effect, even if introduced in the same way as the PBS.

The further concern with copayment policy proposals is the signal it gives for the future. The PBS in 1971 was $1. By 1979 it was $2.75. It is now $36.10. This is a fourfold increase in constant dollars (allowing for inflation). The introduction of PBS copayments was the thin end of the wedge. The introduction of GP copayments is the thin end of another wedge. Copayments will rise and Medicare as we know it will die. This proposal is designed to relegate our public provision of health care to an inadequate safety net for the poor. The rest will pay, and the rich will get the most expensive.

While touted as economically positive, this policy proposal, seen in the broad context of the total cost, is economically dumb. It is also cruel and discriminatory, having most effect on those least able to deal with illness. Copayments kill, but they don’t affect the rich and capable.