Articles
More Links
19th Nov 2024
Health and Human Security: a sense of control over one’s life
Pearls and IrritationsIt is time to think more broadly about security than the narrow military concept about which there is endless debate. Security for individuals and communities does not depend on a nuclear powered and nuclear armed submarine. We are humans and human security is about many things including health, and it is health which our organisation, the Doctors Reform Society, has focused on for the last 50 years. Read more
15th Nov 2024
Putting the mouth back into Medicare
Pearls and IrritationsHow would it be to walk into a general practice with a toothache and be triaged to see the oral health therapist, who assesses and then develops an oral health care plan? They are then qualified to provide dental treatment but may also involve a GP or dentist across the corridor for further assessment. It is time to dream this could become a reality if Labor is prepared to embrace the mouth, gently.
It could be started immediately by listing oral health therapists as part of the primary care team (general practice and others), in the Government’s recently proposed most radical restructure of primary care funding since the introduction of Medicare. Such therapists could focus on oral disease prevention and health promotion. Dentists could be added later.
Currently the radical restructure ignores the mouth. This restructure was initiated by a taskforce chaired by Mark Butler, Health Minister. Further detail on the restructure was addressed by a committee chaired by the First Assistant Secretary for Primary Care. With such senior people driving the restructure one could reasonably expect that suggested changes or a variation of them will be implemented over time.
The Federal Government’s main funding for general practice is through fee for service i.e. you receive a service, and the Government provides a set rebate, the value of which depends on the service. The provider can charge a copayment of whatever value. If no copayment is charged it is called bulk billing. There are other Government payments to general practice for a variety of things which are not related to an individual service. These other payments currently make up less than 10% of Government funding for general practice.
Central to new changes is a move to increase the percentage of general practice funding through non fee for service payments from the current less than 10% to 40%, and adjust them for socio-economic status, rurality, and complexity. Funding will now aim to enable general practices to employ a variety of other health care providers in the practice to promote a comprehensive primary health care team, consisting of GPs, Allied health, nurses, Nurse Practitioners, Midwives, and social support services. Oral health therapists and Dentists are primary care providers. Put them in the list and finally, the mouth is into Medicare.
Importantly, it is suggested that the changes be introduced gradually, with an aim of reaching the 40% target by 2032. This is partly because the changes are quite complicated and cover much more than the above. In addition, the resistance of the medical profession needs to be carefully managed. Lastly, spending extra money on health, education, and welfare is not a priority of this Labor Government unless it has an immediate political impact.
There are a variety of proposals to get the mouth into Medicare. The Greens propose having a rebate system like Medicare to address the issue. There are three problems. Firstly, there is the cost. Labor leadership does not have a ‘crash or crash through’ Whitlamesque visionary who can see the political, economic, and social benefits of equitable access. Minister Butler’s comments reflect that reality. The second is that it would mean adopting a fee-for-service rebate system. That doesn’t work well with doctors’ visits because copayments decided by doctors mean patients can’t afford to go. The same would almost certainly happen with dentists. The Child Dental Benefits Schedule (a limited fee for service scheme introduced in 2014) relies on dentists to participate. Sixty percent don’t, most likely reflecting the fact that eligible patients would not be able to afford the copayments these dentists would charge. A recent review of that scheme concluded there is only a 40% take up of the scheme. The third problem is that it would lead to a federally subsidised dental profession which would then resist any change away from fee for service medicine. That change is precisely what the restructure is intending. It is resisted by doctors’ organisations because it affects their income and autonomy. We don’t need dentists as another adversary to patient centred care. Resistance from dentists was part of the reason Whitlam ignored the mouth in 1974. Doctors’ resistance was enough of a problem then.
Butler said on Q&A recently,
“It’s in our platform that we would one day move to incorporate dental care into Medicare, which conceptually makes sense……We don’t have the ability to [incorporate dental care into Medicare] right now”.
We do. Doing it slowly and carefully is so much better than ignoring it for another 50 years
The mouth has been largely forgotten by Federal Governments since dental care was left out of Whitlam’s Medibank and Hawke’s Medicare for financial and political reasons. The opportunity now exists to start putting the mouth back into the body to address the huge inequities in access to dental care across the country.
12th Apr 2024
Aged Care Funding: On the Road to Entrenched Inequity
Pearls and IrritationsUK Health Minister Aneurin Bevan introduced the National Health Service (NHS) pointing out that “Illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune the cost of which should be shared by the community.”
Advancing age brings with it infirmity and a much higher likelihood of ill health. People do not choose to become old and infirm.
Whilst conservatives despise the sentiments expressed by Bevan, particularly the concept of sharing by the community, liberals do agree, but with very variable degrees of commitment.
Aged Care is a major concern. Recent discussion following the Royal Commission has been about what services should be provided, how to regulate quality, how to get appropriate workforce, and how to fund what is needed.
The main funding recommendations from the recently released Aged Care Taskforce report are means tested co-payments and a safety net to supplement ongoing government funding.
Examples of co-payments and safety nets.
The public hospital system provides first class hospital care to all and if it’s an emergency the care will be timely. If not, unacceptable wait times prevail. Public hospital care becomes a safety net. Those with means bypass the wait times and use the government subsidised private hospital system. Those without suffer.
Primary health care through GPs or other health providers is in theory accessible to all, except for the geographical inequities which have the greatest negative impacts on low-income earners in rural and remote locations. But even in the cities inequities abound. Co-payments make a mockery of affordable access to care. The recently introduced increased rebates for pensioners, health care card holders (HCCH), and children does not mean they will be bulk-billed. It also leaves people just above the cut-off for an HCCH facing an average $40 co-payment per GP visit.
Visits to specialist physicians and surgeons regularly incur a $100 co-payment which sends many patients away and onto the years long waiting list at a public hospital.
A rebate subsidised psychology visit regularly costs $100 co-payment, well outside the affordability of an unemployed patient on sickness benefits, and a challenge to a low wage earner.
The above relate to voluntary co-payments applied by providers. Then there are government-imposed co-payments with safety nets. Prescription drugs are subject to co-payments of $7.30 per prescription for Pensioners and HCCHs and $30 per prescription for others. Despite the existence of a Safety Net, an estimated half a million people delayed or did not fill a prescription in 2021 according the Australian Bureau of Statistics Patient Experience Survey.
No Australian Government in recent history has delivered equity through a co-payment system. Equity in health has been defined by Starfield as ‘the absence of systematic and potentially remediable differences in one or more aspects of health across populations or population groups defined socially, economically, demographically, or geographically.’ The definition could be easily applied to Aged Care and education.
Conservatives are not interested in equity. Successive Labor Governments however, have also shown a lack of commitment. Many Labor politicians would describe themselves as social liberals. Perhaps this lack relates to the reality that equity is not at the heart of any form of liberalism. It is an optional extra, talked about by social liberals as an aspiration, but falling second to the priorities of the individual.
Problems with co-payments, fee-for-service.
Co-payments limit access to items of care. The size of the co-payment is at the whim of the provider or the Government. A Labor Government, led by Julia Gillard from the left faction, introduced a GP co-payment for economic reasons, knowing such payments would be inequitable. The vagaries of economic and political factors determine how much and who will pay.
To determine a co-payment, one needs an item of care. There are some situations where itemised care with appropriate caveats can help to determine appropriate payments. Itemised care, especially in primary health care and Aged Care, leads to a siloed approach, which is completely at odds with the complex care needs in Aged Care and chronic disease. It limits teamwork, including teamwork which involves the consumer/patient interaction with the provider team.
Problems with safety nets
Look at a net. It has holes in it. It sags. It has edges. One could regard the Aged Pension as a safety net. Imagine being a 70-year-old widow whose only work throughout life was low paid, and whose rental cost is 50% of her pension. She has rental assistance, another safety net. She lives below the poverty line.
The Safety Net for prescription drugs helps. But a 20-year-old couch surfer, living with a mental illness, doesn’t register for the net. Even if he did, it doesn’t cut in until he’s spent a certain amount. How does he afford his drugs until then?
The vagaries of economics and politics determine the level and quality of safety nets.
Conclusion
Firstly, when the more powerful and articulate in a community are not subject to the inadequate service provisions of health, Aged Care, and education because they buy their way past such inadequacies, their advocacy for improvements in the system for all is weakened. The safety net sags lower.
Secondly, to adapt Aneurin Bevan’s 1948 quote regarding introducing the NHS: “No society can legitimately call itself civilized if an elderly and infirm person is denied Aged Care because of lack of means”
Thirdly, inequity is entrenched with every introduction of a user pays, means tested co-payment system with safety nets. If Labor does not want inequity, the alternative is funding through an adequate progressive revised tax system.
26th Jul 2023
Prescription Co-payments: Time to Stop the Silent Killer
Pearls and IrritationsPrescription co-payments are imposed by the Federal Government for subsidised drugs. Australians pay $1.6 billion a year in co-payments. Why do we continue to have financial barriers to accessing these drugs?
Co-payments are $7.30 or $30 per prescription for Pensioners and Health Care Card Holders or the remainder respectively. Scotland, Wales, and Northern Ireland abolished prescription co-payments in 2011. New Zealand has just abolished co-payments in July 2023.
Purpose of Co-payments
Co-payments in general are designed to reduce inappropriate use and to generate income. Some also believe that without co-payments the consumer will not value the product appropriately. In terms of medical care that sad view of human nature would appear to contradict my reality of many gifts and thanks from my bulk billed patients. Humans value good service. They value prescriptions which help.
Determining appropriate use of prescription drugs is the task of the prescriber, not the patient. Arguments for co-payments to reduce inappropriate use are nonsense.
Co-payments are taxes, levied on those unfortunate enough to need prescription drugs. People do not choose illnesses. One must ask if the purpose of co-payments is therefore also to punish the sick?
Health and Social Impacts of Co-payments
Prescription drugs are approved for listing on the PBS because they have been shown to save lives and/or reduce severity of illnesses. However, multiple studies show a reduction in use of medication with introduction or increase in co-payments. Repeated surveys over decades have reported that patients delay or do not fill prescriptions because of costs. Half a million people delayed or did not fill a prescription in 2021 according the Australian Bureau of Statistics Patient Experience Survey. The largest effects are in those living in areas of low socio-economic status, the elderly, those with long term health conditions, and females. There are widespread reports from doctors that their patients are reducing the dose or taking the drug every second day to save money.
It is well established that mortality and morbidity correlate with income, socio-economic status, and postcode. Access to health care probably accounts for 20% of the differences in life expectancy in first world countries. Socio-economic status accounts for most of the rest. Cost barriers are either met by decreased usage of life saving drugs or forcing the most vulnerable to pay co-payments and forgo spending on other basics in their lives which contribute to improved socio-economic status.
Studies of the direct effect of prescription co-payments on health show for example, improved compliance with taking heart medication if drugs are free, increased adverse events after the introduction of co-payments, and most recently a study in New Zealand showed decreased hospitalisation rates across a variety of medical conditions following the removal of co-payments for a selected group.
Economic Impact of Co-payments
An inflation adjusted figure from the Australian Institute of Health and Welfare 2012 data indicates that the day cost of a public hospital admission in 2013 is $1300. The Grattan Institute estimates there are 750,000 potentially preventable hospital admissions adding up to three million unnecessary days in hospital per year . Most of these are due to inadequate primary health care which includes financial barriers to access as well as adverse socio-economic factors. The government would only have to see a reduction of 185,0000 admissions across Australia to have easily saved the estimated $1.2 billion cost of abolishing all co-payments. Whilst the causes of these preventable admissions are multiple, medication compliance is likely to be a significant part of the problem. Improving compliance by abolishing co-payments will save money and reduce the net cost. It might even be budget neutral.
Thus, we have both an ethical and an economic argument for abolishing co-payments.
Current Policy Initiatives
The current Federal Government has done well with respect to reducing cost barriers to accessing prescription drugs. It implemented a reduction in the general co-payment from $42 to $30 in January.
It has since taken on one of the most powerful lobby groups in Australia, the Pharmacy Guild by extending prescription lengths from the usual month to two months. This halves the cost to patients for many drugs.
It has supported the concept of increased prescribing by pharmacists for some specific limited conditions, thus saving patients the challenge of finding and paying for an appointment to get a prescription. These changes combined will lead to a decrease in revenue from patients from $1.6 billion to about $1.2 billion.
It has maintained safety nets so that over a year there is a limit to how much one pays per prescription. But just because a safety net kicks in after a patient had spent $262 or $1563 (different depending on Health Care Card) on drugs for the year, this might not happen until May or October. It doesn’t help the budget in March or January.
What Now?
More should be done. The Federal Government updated its National Medicines Policy in February this year. The stated aims of the policy include that
All Australians have fair, timely, reliable, and affordable access to high-quality medicines and medicines services.
It’s time to align actual policy with the above. Co-payments continue to be a financial barrier to accessing lifesaving medication. Co-payments kill, lead to more hospitalisations, and waste money. It’s time to axe killer co-payments.
21st Jan 2023
Medicare Needs Reconstructive Surgery Now, not Band-aids
The Medical RepublicStructural problems won’t be fixed by doubling rebates. Voluntary patient enrolment can improve access if funding varies with SES.
Our health services are struggling. For patients, even the wealthy, it can be difficult to access timely care. For all patients there is no ‘system’. They see a collection of poorly connected, differently funded services which they are expected to negotiate. Read more
3rd Dec 2022
Rorts and Revamping Medicare
Rorts and Revamping Medicare
This series of three articles looks at the above topic under the headings:
- The Vision: Where could we be?
- The Reality: Where are we now?
- Implementation: How do we proceed with the needed changes?
9th Oct 2020
Opportunity Lost: Covid-19 and the Budget
“The many problems in our society exposed by the Covid-19 pandemic and the response to it have been largely ignored by the Federal Government’s budget”, said Dr Tim Woodruff, President, Doctors Reform Society. “Residential Aged Care has been ignored. Aging in the home has been trickle fed. 1.6 million unemployed have been left in poverty on Job Seeker, waiting for the job creation which will be slow and painful. Poverty kills. And the middle aged unemployed have been left on the scrapheap, despite being much more likely to have dependant families, and sadly perhaps because women make up a much larger percentage of this group”. Read more
30th Jul 2020
The Powerless Suffer and the Powerful Carry On Amid Covid-19
Source: Pearls and IrritationsCovid-19 presents us with an opportunity. A more equal society, more resilient to the challenges ahead, or a society ruled by power imbalances, struggling to cope with both natural and man-made disasters. Read more