GRAEME STEWART. Major holes in Medicare.

For a very large and growing number of poorer Australians, the high out-of-pocket expenses for medical care in Australia to which Ross Gittins refers (SMH ‘Prevention is better than cure’, April 24), are tearing major holes in the safety net Medicare was designed to provide to us all, rich and poor. 

One large hole is access to specialist consultation for people who cannot afford the fee gaps in the private sector and for whom the waiting time in a public hospital clinic, if it exists, is far too long. In western Sydney, many GPs have all but given up for what is now an underclass of sick people. A single consultation with an expert can provide the patient and GP with a definitive diagnosis, a long-term management plan and a high likelihood of avoiding future unnecessary suffering and hospital admission. But if the patient or family can’t afford the fee gap, forget it.

The solution is straightforward.  Fund outpatient clinic expansion in the public hospitals and there are many young specialists prepared to see patients in them without charge to the patient. They will do so in order to give back to the system that trained them, to continue to work with the professor that mentored them and to participate in intellectually stimulating highly specialised and multidisciplinary services, teaching and clinic-based research. Enhanced competition from the public system will also put downward pressure on the gaps charged in private consultation.

When the Labor Party announced in February its intention to establish a National Health Reform Commission, it listed amongst three priorities increased access to public hospital specialist consultation. To date, policy has been announced only for cancer patients. This is a good start but less than 10% of the need.  It is hoped that before May 18 more detailed policy will emerge on establishing expanded specialist clinic access for all patients facing risk of all forms of serious illness. The even greater hope is for the Coalition to match this policy.

Specialists are becoming the doctors only rich people can afford and I find that deeply offensive. As a nation, we are better than that and Medicare used to prove that we were. With bipartisan commitment and state-commonwealth co-operation, it can do so again.

Prof Graeme Stewart, Westmead Hospital.


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6 Responses to GRAEME STEWART. Major holes in Medicare.

  1. Avatar Malcolm Fisher says:

    This is compounded by the closure and/or privatisation of hospital out patient clinics. A gap of up to $300 for a specialist consultation is the food money for some people. There are people in NSW going bankrupt over medical bills which simply should not occur.

  2. Avatar Michael Rogers says:

    Of further interst may bet this W.H.O. report on ‘out of pocket’ expenses in the U.K. National Health Service.

    Although the 1946 amendment of the Australian Constitution gave powers to the Federal Government in relation to provision of medical services, limits were put on making doctors ’employees’ of the government (which would be one way to regulate payments for their services).

    3.21 Subsection 51(xxiiiA) contains an express prohibition on the use of the medical services power ‘to authorize any form of civil conscription’.

    3.22 The submission of Catholic Health Australia provided a helpful description of the events that led to the inclusion of subsection 51(xxiiiA) in 1946,[40] which included the explanation that the prohibition on civil conscription was inserted to allay fears that ‘the proposed amendment would grant the Commonwealth the power to nationalise medical and dental services’.[41]

    3.23 The prohibition on civil conscription has been described as referring to:

    …any sort of compulsion to engage in practice as a doctor or a dentist or to perform particular medical or dental services. However, in its natural meaning it does not refer to compulsion to do, in a particular way, some act in the course of carrying on practice or performing a service, when there is no compulsion to carry on the practice or perform the service.[42]

    3.24 Importantly, the prohibition on civil conscription only applies to the provision of ‘medical and dental services’ and not to the other elements of subsection 51(xxiiiA).[43]

  3. Avatar Donald Kent says:

    I think Prof Stewart is right, the public hospital public health clinics do need more funding AND involvement of senior specialists, with an emphasis that this should not be a blinkered isolated approach to reforming our health system – it will not work by itself and by itself it will likely worsen the problems (inequality, standard of care, waiting time, efficiency etc) of what we are already working in right now.

  4. Avatar Donald Kent says:

    Post #2:

    Extending point 1 for non-medical readers, the concerns are the newly minted specialists (but more than likely unaccredited and accredited registrars) will cost the health budget and health of Australians more because of:

    – over-investigation (leading not only to waste of resources but more opportunities for complications from further investigations, procedures and treatments arising from false positives and negatives)

    – over-servicing (to gain experience, satisfy quotas, as a result of not being experienced in non-tertiary presentations and unfamiliarity with returning patients especially with the foreseeable and expected churning of doctors who staff these clinics)

    – poor communication and relationship with the primary care system (and consequent health and health budget problems): the realtiy that no-one dares to openly say is, most students and registrars learn or are deliberately taught to distrust and look down on GPs and their referrals and care of patients, and there is very little reliable and/or consistent communication and teamwork in any location I have personally been at where patients move between primary and tertiary care systems (including public hospital outpatient services)

    NB. For non-medical readers, medical training system is as follows: student, intern, resident, unaccredited registrar, (pass entrance exams to specialty), accredited registrar (junior, senior, fellow), (pass exit exams to specialty certifying standard consistent with minimal specialist licence), new specialist / consultant with little experience in dealing with presentations not requiring going to the hospital / hospitalisation and the primary care system / GPs, more experienced specialist / consultant who may or may not have experience with presentations that are not tertiary (eg, a specialist who mainly works in the hospital) or presentations that are not in their subspecialisation (eg, an experienced orthopaedic surgeon who is subspecialised into hips and knees will unlikely to be happy seeing a tertiary referral for the shoulder).

  5. Avatar Donald Kent says:

    The issues with this solution for the National Health Reform Comissions to address would be:

    1. current outpatient clinics are usually staffed mostly by unaccredited (ie, non-specialist but training) registrars and rarely by accredited registrars (ie, specialist but still training registrars). See below for more detail.

    2. the unresolved complex incentives and disincentives of a federally funded Medicare and state funded public hospital outpatient service

    3. the phenomenon in international systems where a weak general practice and a overly supported and well-funded public specialist system led to extensively expensively trained specialists seeing 60+ presentations per 4-hour session (to clear backlog and meet administrative targets), most of which presentations are general practice (which, apart from the waste of resources and the clog up of specialist care, also means the specialists gain the same reputation as GPs in Australia for missing diagnoses and/or making wrong diagnoses, over-investigating, under-investigating etc)

    4. after clearing backlogs and treating conditions that would otherwise progress to more expensive care with poorer standard of living, the system will predictably morph into a monster (issues are overservicing, overdiagnosis and treatment etc because money needs to be spent, doctors need to be trained, staff need to be paid, GPs have finally be made fully redundant etc, and the perverse relationship that already exists between private and public care where presentations that are profitable and easy / simple / no risk of complications /complaints / failures are seen in the private sector and others and/or problems that arise are shunted into the public). This monster will also need to try to sustain itself (especially if the current public hospital budget system of ‘if you don’t use it you lose it’ is applied to this service), again with foreseeable negative consequences.

    5. a similar situation to the first home owner’s grant (in NSW) and the RBA dropping interest rates in an unaffordable property market is also foreseeable (or rather, is already occuring, but still limited); and the expectation of charging even higher private fees after this extra period of ‘voluntary’ internship (training doctors are well aware they are expected to work harder for poor compensation during their registrarship and fellowship and recoup this after they graduate with a specialist fellowship)

  6. Avatar Niall McLaren says:

    When I needed an anaesthetic recently (for sinus surgery and excision of cervical nodes, say 45mins max), the quoted fee was the Medicare fee plus Medibank plus $400. Fortunately, I was recognised and only had to pay an extra $200. For a gasser, a gap of $400 per procedure amounts to a very large sum of money over the year, say $500,000 in addition to the $300,000 that Medicare etc. pay. That, by any estimation, is gouging.

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