Pearls and Irritations

It is quite challenging to reconcile headlines like ‘Record number of Australians raid super to fund medical treatments’ with a health minister’s statement claiming, ‘Medicare top performing health system in the world’.

The 20 September statement by Minister Mark Butler was referring to a Commonwealth Fund report ranking Australia’s health system as the top performing country in 2024.

Health policy analyst Charles Maskell-Knight digs behind the headlines about the report, suggesting that its findings are not as positive as they may first sound.

“If I were to summarise the report’s implications for Australia, I would say it shows that we have a world class health system – unless you are unfortunate enough to get ill,” he writes below.

Charles Maskell-Knight writes:

Last week the Commonwealth Fund, a United States health policy think tank, published the latest edition of its regular comparative review of international health system performance across ten wealthy countries.

This year Australia was ranked as the best performing – an achievement recognised by Health Minister Mark Butler in a media release.

However, as the Commonwealth Fund pointed out, “the top three countries are Australia, the Netherlands, and the United Kingdom, although differences in overall performance between most countries are relatively small”.

“The only clear outlier is the US, where health system performance is dramatically lower.”

It is also worth remembering that the point of the exercise is not to produce definitive rankings of health system performance, but rather to compare the US to other countries with a view to identifying opportunities for US system improvement.

But accepting these caveats, what does Australia’s top ranking actually mean?

The Commonwealth Fund measures performance against five “domains”: access to care, care process, administrative efficiency, equity, and health outcomes.

Each domain has a number of related performance indicators. A total of 70 indicators are used in the assessment, drawn from a wide range of data sources, including Commonwealth Fund surveys and national statistical agencies. This edition reflects the impact of COVID-19 on health systems, as no pre-2020 data are used.

So how did Australia achieve the top ranking?

We were ranked first for the health outcomes and equity domains, second for administrative efficiency, fifth for care process, and a dismal ninth for access to care.

Health outcomes

The performance indicators under this domain fall into two categories: population health measures and mortality amenable to health care.

Australia has very high life expectancy at birth, and we do well on preventable mortality and treatable mortality.

The Australian score on “Excess deaths associated with COVID-19 pandemic from all causes, age standardised per 100,000 <75 years” was the best in the study.

However, the score on “Excess deaths associated with COVID-19 pandemic from all causes, age standardized per 100,000 >75 years” was not as good, reflecting the high toll from COVID-19 in residential aged care.

Equity

Scores under the equity domain are based on comparing system performance for higher- and lower-income individuals within each country against nine measures: eight measures on access to care or care process measures, as well as self-reported health status.

Australia generally performed well on these measures, with the exception of the “had serious problems paying or was unable to pay medical bills”, where the differential between above-average and below-average income groups was one of the highest in the study.

The report also presents the results of comparing countries on the same measures by examining differences based on location (rural versus nonrural) and gender (female versus male), although these results were not used in the final rankings “as we were not comfortable weighting rurality and gender at the same level as income”.

From an Australian bragging rights perspective this is a good thing, as Australia is the worst ranked of the 10 countries in the study when rural versus non-rural equity is assessed, and sixth out of 10 when a gender focus is used.

Administrative efficiency

Australia ranked second behind the United Kingdom in this domain, which includes measures on doctors’ experience in dealing with funders and other bureaucracy.

This is despite the Royal Australian College of GPs’ claims that “many GPs are exhausted with the bureaucratic nonsense”.

Another performance indictor under this domain is “patients who visited emergency department for a condition that could have been treated by a regular doctor, had he/she been available, in the past two years”.

Again, despite regular suggestions that emergency departments are being clogged up by “GP-type patients”, Australia has the third-best performance against this indicator.

Care process

This domain measures performance against 35 indicators grouped into the sub-domains of preventive care, engagement and patient preferences, safe care, and coordinated care.

It is essentially a measure of how well the health system works technically to help keep people well and look after them when they are sick.

Australia is ranked in the middle of the field on this domain – second on preventive care and engagement and patient preferences, ninth on safe care, and eighth on coordinated care.

The poor score on safety is driven by high rates of postoperative sepsis after abdominal surgery and postoperative pulmonary embolism in hip and knee replacement discharges.

The poor score on coordination reflects both a lack of coordination within the system (specialist lacked medical history or regular doctor not informed about specialist care; primary care physician is not usually notified when patient is seen in emergency department), and between the health and care systems (primary care physician does not communicate with home-based nursing care providers about patients’ needs and services to be provided; practice does not coordinate care with social services or community providers).

Australia has invested a lot of effort (and a not inconsequential amount of money) over the years in efforts to improve coordination – for example coordinated care trials version one and two, health care homes, and now the innovative models of care program.

But there is clearly a long way to go when even the US is doing better.

Access to care

It is against this domain that Australia’s performance falls down badly – we are rated ninth out of ten.

The domain includes the sub-domains of affordability and availability.

On affordability, Australia is ninth overall (in front of the US), with poor rankings for indicators including “had any cost-related access problem to medical care in the past year or skipped dental care or check up because of cost in the past year”, “insurance denied payment for medical care or did not pay as much as expected”, and “had serious problems paying or was unable to pay medical bills”.

On availability, we were fifth overall, with poor rankings on many indicators relating to timely access to appointments and treatment.

Just don’t get sick

In summary, Australia achieves good health outcomes, but this is due to social determinants of health as much as the health system.

The system is reasonably equitable as far as income is concerned — although people living in non-urban areas have a far worse experience than those in cities — and it operates with a high level of administrative efficiency.

However, the quality of care delivered by the system is only average, while the level of practical access to it leaves a lot to be desired.

Minister Butler’s response to the Commonwealth Fund report stressed the measures the government has taken to improve GP bulk-billing, and then said, “there is still so much work to do… It is going to take time to repair the damage of a decade of Liberal cuts and neglect to Medicare”.

There is a lot more to Medicare than GP bulkbilling, and there is no sign that the Government has plans to tackle problems in other areas.

Nor is there any progress on the new public hospital funding agreement, which might help address public hospital access issues.

Where I live on Yuin country on the NSW south coast, co-payments for GP services are $55, the co-payment for a CT scan or an ultrasound is $150, and a consultation with a specialist has a waiting time of several months and a co-payment of $150.

The nearest level 4 hospital with a reasonably comprehensive range of elective surgery specialties is two hours’ drive away, and many procedures can only be carried out in Canberra after an extended waiting time.

As far as specialist consultations are concerned, this is not atypical. The Australian Institute of Health and Welfare monthly Medicare billing data shows that the average proportion of fees for specialist consultations met by Medicare fell to a historic low of 52 percent earlier this year.

If I were to summarise the Commonwealth Fund report’s implications for Australia, I would say it shows that we have a world class health system – unless you are unfortunate enough to get ill.

 

Republished from Croakey.org, 24 September 2024.