The foundation of the Australian health care system is primary health care. As its name implies, primary care normally provides the first point of contact between a person and the health care system. The key elements of the primary care system include general practitioners, community nursing services, community health centres, and a range of other first-contact providers.
Failures in the primary care system cascade, causing problems at all other points of the health care system. Delays in treatment in primary care can lead to exacerbation of conditions, but early intervention can reduce overall costs of care. An important function of the primary care system is to provide assurance to patients and their families about whether conditions can be managed at home, or whether additional services are required. It is thus an important point for assurance and reducing anxiety.
Failures in ensuring access to the primary care system have crucial rebound effects on the whole health care system.
Australia has a relatively good primary care system, and until recently could be proud of the key design elements of that system. Access to primary care is a crucial underpinning of a well-functioning health care system, and threats to that system must be viewed with grave concern.
The key positive element of the primary care system has been access to primary medical care. Since 1984, Medicare ensured that in most cases there were no financial barriers to access to general practitioner services and families could visit a general practitioner to seek treatment and reassurance without having to worry about meeting the costs of that visit directly. In 1996/97 81% of all general practitioner services were bulk billed, and patients did not have out-of-pocket costs for those services. Bulk billing rates were slightly higher in metropolitan areas and slightly lower in rural areas. Bulk billing rates had steadily increased from 1984 to 1996, but from 1996 this trend had reversed and bulk billing rates started to decline, meaning that families faced increased out-of-pocket costs for visits to doctors. By December 2003 the rate of bulk billing had dropped to a nadir of 66.5%.
This decline in bulk billing is the single most important threat to universal access to health care in Australia.
The political responses of the Government and the Opposition to the bulk billing decline are very different. The Government’s responses, both before and during the election campaign, undermines universality and segments the population into separate population groups for which general practitioners had different incentives to bulk bill. The œin groups include the aged, services for children, and people in rural and remote areas, and Tasmania. The initial Government policy, which was accompanied by an extensive taxpayer-funded advertising campaign, also allows bill manipulation by medical practitioners to transfer over-billing costs from patients or health insurance funds to the Commonwealth. Government policy also facilitates general practitioners charging above the scheduled fee by changing the way rebates were processed for the rest of the population. As expected, the costs of the Government’s scheme have blown out. The effect of the Government scheme has been an increased in bulk billing rates from 66.5% in December 2003 to 70.7% in June 2004. The election-eve decision to shower an additional $1.8b on general practitioners will benefit doctor incomes, will probably be inflationary with little impact on patient moieties, and lead to no change in bulk-billing.
The Opposition’s approach, in contrast, is to maintain universality and to place more wide-ranging incentives on general practitioners to bulk bill all people in the population.
The primary health care system, however, is not only about primary medical care. There are other key aspects to the system such as home and community care and access to allied health and community nursing services. Government support for these programs is extremely uneven. There are a number of government programs such as home and community care, which does provide targeted access, especially for the elderly, to these services. But home and community care programs are very unevenly distributed, both geographically (rural versus metropolitan), within metropolitan areas (especially in States such as Victoria where local government plays a key role in service provision) and between States, with different States having different emphases in their programs. There is no Australia-wide standard for access to home and community care and so two sisters living in different States can have vastly different access to support to help them stay in their own homes.
Similarly, community health services for the wider population are very unevenly distributed, with government-funded community health services having quite different accessibility standards, essentially reflecting historic decisions of the Whitlam era about government funding of community health services. Although policies on out-of-pocket costs for all these services are now more or less uniform and there is a move to a common national standard schedule of user charges, the different geographic availability is a significant threat to universality.
Government support for primary care also comes through the 30% Health Insurance Rebate. Allied health services, dental services and community nursing services, are all reimbursable through ancillary insurance arrangements provided by private health insurance funds. About 43% of the Australian population have private insurance, and the Government subsidises most elements of benefit expenditure by the funds through the 30% Health Insurance Rebate. Health insurance, of course, is not evenly distributed in the Australian population, with a slight skewing to the wealthy and with different rates of health insurance take-up in different States. Again, this major element of government support to these services is therefore not allocated on the basis of principles of universality, nor is it targeted on those with poor incomes or greatest need, but rather appears to be targeted to those who would, on the face of it, be most able to afford to purchase the services without the government support.
Although policies about general practice bulk billing provide the contemporary battleground for issues of universality, governments of both persuasions have a predilection towards targeted programs and de-emphasise the social benefits of universality, particularly in promoting a cohesive society and giving all people a stake in high quality public services, from universal policies. The policies on the Health Insurance Rebate, for example, provide additional support to those who take out health insurance, yielding particularly perverse policies where Commonwealth Government support for dental care is targeted to a relatively wealthier population (those with health insurance) rather than a relatively poorer population (those without health insurance but with higher dental needs).
Universality needs to be reinforced as an underlying design principle of Australia’s health system. Although targeting is an important way of limiting government expenditure, the basis for targeting needs to be thought through carefully. Age and low income, for example, would seem to be more socially just targeting mechanisms than those with health insurance.
How can we move forward? Clearly progress is, to some extent, a matter of social choice and political disposition, but value choices are becoming blurred in the political debates of the 21st century.
The first step in any new policy on universality and access is to reinforce the absolute imperative for there being no financial barriers to primary medical care. These services provide a gatekeeper to a range of other services, and provide reassurance about the need for further investigation and treatment in the more expensive parts of the health care system. But the primary medical care system, as has evolved since the 19th century, is probably no longer the right place to start for a 21st century system. Not everything that is done in primary care needs to be done by a medical practitioner, and our existing Medicare arrangements probably distort service delivery in an unhelpful way, leading to inefficiencies and workforce shortages.
The ideal primary health care system ought to have as a foundation a multidisciplinary services, with doctors, nurses, allied health professionals, all accessible to those in need. A multidisciplinary work environment would also mean that medical practitioners in primary care would be able to focus on higher order cognitive tasks, and thus use their skills better and hopefully retain medical practitioners in the system. Nurses would be able to manage many minor conditions and the use of nurse practitioners would extend the available workforce and help address the current perceived shortage of medical practitioners. Allied health professionals, who have particular skills which supplement both doctors and nurses, should also be available in this new model of care.
Health policies, then, need to be structured about how to encourage this sort of service delivery, and how this sort of service delivery can be made accessible to all Australians regardless of geography and financial barriers. It is only when this range of services is accessible and covered by similar financial arrangements can we be sure that we have a universal system which is both equitable and efficient.
This article first appeared in New Matilda’s Policy Think Tank section.
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