There is a lot that is disturbing about the federal government’s flirtation with a $6 co-payment for a service from a GP. Most commentators have rejected this approach as poor public policy as it will act as a deterrent for poorer Australians to seek the care they need to provide paltry savings in a 120 billion dollar a year health system. This policy will cost all of us dearly as avoidable chronic illness among those less economically secure already absorbs so many of our tax dollars. With the exception of illness caused by excessive alcohol consumption, all risk factors for serious disease are more prevalent in less advantaged Australians. Studies show that already too many patients delay seeking help and fail to take prescribed medications because of the costs involved. Health care in our wealthy country is distressingly and increasingly inequitable.
However the major frustration with the current debate is associated with the lack of political understanding of the changes we do need to make to provide better health outcomes from a system that is financially sustainable. Cost effectiveness can only be tackled with a whole of system analysis not just a focus on the federally funded Medicare program that supports our delivery of primary care.
The compartmentalisation represented by Minister Dutton’s focus on the cost of Medicare is the price we pay for the wretched jurisdictional separation of funding arrangements for Hospital and Primary Care services in Australia, the only OECD country so burdened. Hospital expenditure dwarfs primary care expenditure so looking at the cost of funding Medicare divorced from a system wide analysis of health care costs is nonsensical. In the actual health care delivery world the success or otherwise of our Medicare funded primary care system has a major influence on how much we need to spend on hospital care. Indeed the pertinent truth is that hospital funding into the future will only be manageable if a modernised and remodelled primary care system can reduce the demand for hospital admissions.
We need and want a national health care system characterised by its resourcing of evidence based strategies that prevent avoidable illness and the provision, in a timely manner to those who are ill, cost effective quality care available on the basis of need and not personal financial wellbeing. These are not Utopian goals but their delivery will require additional spending in a number of areas. However there are major savings that can be made in our current system that would fund a remodelled health system. For example, nine departments of health to service 23 million people are not only cost ineffective ($4 billion a year in duplication costs) but also makes proper integration of services impossible. 30 years of working closely with State and Federal health bureaucrats has taught me that the system sees good people more concerned about saving dollars in their patch and maintaining their power base than providing patient focussed integrated care. We need the Commonwealth to be the single funder for our public health system contracting with providers to deliver the integrated system describe above.
Remodelled Primary Care with the infrastructure for the support of prevention programs is the most important initiative we need to implement in Australia. Around the world the trend is to establish primary care systems that encourage citizens to enrol in a wellness maintenance program and benefit from the delivery of health care by teams of health professionals working as “first among equals” in the one practice (Integrated Primary Care” (IPC). The psychology associated with voluntary enrolment is important .The philosophy involves acceptance of the concept that we need to take more responsibility for our own health but with personalised and ongoing assistance, when necessary, from appropriate health professionals. 85% of our New Zealand cousins are voluntarily enrolled in a “Primary Healthcare Organisation”.
The Productivity Commission reports that between 600,000 and 750,000 public hospital admissions could be avoided annually with an effective community intervention in the three weeks prior to hospitalisation. An average hospital admission costs at least $5000 while a community intervention to prevent that admission would cost about $300. Primary Care infrastructure in Australia needs to resource the needed community interventions. The savings would more than cover the expense of introducing Integrated Primary Care into Australia.
The introduction of IPC in Australia is likely to attract more medical graduates into a career as a GP. Research tells us that only 13% of medical graduates in Australia plan a career in Primary Care. Remuneration is poor compared to other specialities.The need to bulk bill puts time constraints on episodes of care resulting all too often in “turnstile medicine “which is unsatisfactory for both doctor and patient. A young graduate will not be impressed with the Abbott government’s decision to cap Medicare payments to doctors for four years. Many younger doctors considering general practice would prefer to move away from the traditional “fee for service” payment system to salaried or contractual payments. Watching the journey that is leading to IPC in other countries can teach us a lot. In New Zealand over 85% of GPs have voluntarily forsaken “fee for service” payments in favour of guaranteed remuneration in a capitation model.
The Abbott Government should commit to taking us on a health reform journey that embraces the above changes and the introduction of a single funder for our health system. To be talking about $6 is to trivialise a major policy challenge.
Professor John Dwyer is the Emeritus Profess of Medicine at the University of NSW.