Co-payment policy 101

The Government has been strongly criticised for its selling of the GP co-payment policy but many experts and stakeholder groups would disagree that the problems with the proposed $7 bulkbilling co-payment are merely cosmetic. 

The following 8-step guide highlights some key pre-requisites for the development and implementation of a new health care co-payment.  It should assist in assessing whether or not the proposed Budget initiative is fundamentally bad policy or just suffering from a poor sales pitch. 

8 Steps to a Successful Co-payment    

1.       Reflect community views

Find out what the community thinks about health care funding BEFORE attempting to introduce any new co-payments.  Are Australians concerned about our level of health care expenditure or are we comfortable with spending around the OECD average on health services?  Do we want to fund health care completely through progressive taxation or are we happy to contribute a certain component of health funding through direct payments?  If so, what proportion of health expenditure should be made up of out-of pocket payments, given that we already pay for a higher proportion of our health care costs through direct payments than do citizens of most other countries? Finding out community values and priorities for health funding before introducing a new payment will help avoid nasty shocks at the polls later on.

2.       Think about the impact on Indigenous Australians

Overall Australians enjoy a life expectancy that is among the longest in the world. However, Aboriginal and Torres Strait Islanders continue to experience higher than average rates of preventable disease and disability and die – on average – around a decade earlier than non-Indigenous Australians.  Gains are being made to close this ‘health gap’ and all governments should place the highest priority on supporting the positive work being done to improve Indigenous Australians’ health and well-being.  Any proposed new funding measures, such as a co-payment, which risk creating barriers to accessing care for Aboriginal and Torres Strait Islander Australians, should be automatically rejected.

3.       Measure against Medicare

Listening to the Government’s rhetoric about ‘those who can pay should pay’ it’s easy to forget that we already have a health funding system where people contribute when they have the capacity to do so and receive benefits when they require care.  No funding system is perfect but Medicare certainly scores highly on efficiency, access and equity grounds.  Any proposed new co-payments should be measured against the ‘gold standard’ of Medicare and only be introduced if they, in some way, improve on our existing system.

4.       Leave GPs out of it

GPs are busy people doing some of the most important and cost-effective work in the health system.  They and their staff already have enough to do without collecting a tax on behalf of the Government.  Shafting responsibility for collecting co-payments onto individual GPs vastly increases the transaction costs of the payment system and puts more stress on an already over-stretched general practice sector.  There are a number of existing Government agencies which are ideally set up to deal with population-wide payments and transfers.  They have the information systems, IT infrastructure and staff in place to process large numbers of small payments efficiently and they can do so without the added distraction of having to simultaneously diagnose and treat a myriad of illnesses.  Give Centrelink or the ATO the responsibility for dealing with co-payments and let GPs get on with the job of providing high quality health care.

5.       Listen to consumers

If consumers say that they will have trouble affording a $7 co-payment then – rightly or wrongly – the Government needs to accept that this is the case.  No matter whether politicians (or their family members, friends or ComCar drivers) think that $7 is small change, there are people in the community to whom this is an unsurmountable barrier to accessing health care.  These people should be listened to and respected.

6.       Take a reality check

Base any new funding mechanisms on typical – rather than ideal – health care environments.  Just because a co-payment works for the busy executive hopping into a clinic on her lunchbreak for an annual flu shot does not mean that it will work for a pensioner with diabetes, early stage prostate cancer and dementia, or a young person experimenting with drugs and experiencing the signs of psychosis.  People with multiple, complex physical and mental health problems are the ‘normal’ of general practice. Any co-payment system needs to work for them or it will not work at all.  

7.       Target low value services

If a co-payment is designed to reduce unnecessary demand and increase overall health system efficiency it needs to target low value services.  Primary health care and preventive health are among the most cost-effective sectors in the health system.  A blanket co-payment for these services risks creating barriers to access and pushing people into the higher cost hospital sector.  Research identifying low value services routinely provided in the Australian health system should be used to target co-payments at those services unlikely to provide good value to consumers or the community.

8.       Repair the safety-net

Any health funding mechanism that imposes vastly different payments on individuals, based on factors largely outside of their control, is inherently inequitable.  A well-designed safety-net can go some way towards addressing this inequity but the current safety-net arrangements (the Medicare and PBS safety-nets, plus assorted individual programs targeting specific areas of need) are woefully inadequate to this task.  Among their many problems are their administrative complexity, their focus on single areas of the health system (as though going to the GP and filling a prescription are two completely unrelated activities), their requirements for burdensome record keeping on the part of consumers and their inability to adequately support people with chronic conditions requiring multi-disciplinary long term care.  A single safety-net which includes all forms of health care services, including medical and allied health care, dentistry, medicines and devices, is an essential pre-requisite to ensure that any new co-payments do not compound existing inefficiencies and inequities.