Out-of-pocket costs for health care are becoming an issue that the Government cannot afford to ignore. Peter Brooks AM MD, Professor, School of Population and Global Health, University of Melbourne, adds his voice to the growing chorus of experts, peak bodies and commentators who are pushing for action in this area. He writes:
Early this month the Medical Journal of Australia reported that out of pocket expenses (those medical fees that you are required to pay to the doctor over and above Medicare or what your private insurance covers) reached $28.7 billion for 2009-2010. This is almost a quarter of the total health care ‘bill‘ for Australia . A recent article by Farhat Yusuf and Stephen Leeder in the Medical Journal of Australia reported that the mean total out of pocket expenses for older households was over $3500 per household and not much less for those households without a person over 65 ($3377) This means that Australians are paying more out of pocket for their health than most other nation. So how can these fees be justified – who decides what is a reasonable cost for a procedure and possibly more importantly is the procedure even justified in the first place?
This debate is starting to shift – as indicated by the recent publication from the Consumers’ Health Forum Health Voices. This edition of the regular journal contained an excellent series of articles highlighting key issues, such as nearly 20% of health expenditure in Australia is funded directly by consumers and that this is really starting to impact on senior Australians and other vulnerable consumers. The articles also make a strong case that growing out-of-pocket costs promote inequity in access, thus undermining one of the basic tenants of the Medicare system.
A number of the authors identify (yet again) the low hanging fruit: having a real debate about how we pay doctors differently; moving away from a fee for service system; and adopting recommendations of the WHO report Closing the gap in a generation: Health equity through action on the social determinants of health. The latter would result in significant health and economic gains such as a $4 billion saving in welfare support and fewer people suffering chronic illness and being admitted to hospital. In fact, research by NATSEM shows that this would achieve savings of at least $6 billion and $8 billion generated through extra earnings of folk now able to work – not in total – but every year . Read these articles and ask yourself should there even be a ‘gap ‘ between what the doctor charges and what Medicare or the health fund pays – some countries like Canada don’t allow this – so why not us? But the really telling articles in this issue of Health Voices come from consumers – people who can tell real stories – suffering from disease and trying to cope with paying for the care that they need in an ever more complex world.
When considering the costs of medical care we might also want to look at whether a recommended procedure is necessary or not. A recent study by Dr Adam Elshaug et al found 150 procedures- investigations and operations that could be classified as ‘low value’- ineffective or unsafe. These include things like imaging (MRI, CT or plain Xray ) for low back pain, arthroscopy for knee osteoarthritis, vertebroplasty and surgical treatment for obstructive sleep apnoea. Now the profession will argue about these data – and we should have an open debate about them – but the community needs to be aware that there is some doubt about the usefulness of many of the investigations and treatments we deliver. So the discussion about out of pocket charges surely changes somewhat – after all it is one thing for a doctor to charge extra because he or she thinks they can command an extra fee – but if the fee is being charged for something that may be ineffective or may cause harm that surely is something different.
So maybe we – the people – can seriously start this debate and direct it at 2 groups. Firstly our politicians, though it is unlikely any will show the leadership to do that despite the billions of dollars it would save the health system and which could be redirected to health interventions that really do work. Secondly, to our health providers, doctors, nurses, chiropractors and others to ask them to explain what and why they are suggesting/ telling us to do with our bodies. It is, after all our body and we should have real say in what is done, by whom and at what cost (and remember – even if it is Medicare-only we all pay for this through our taxes!) .
But to do that we must increase health literacy across the board and get serious about shared clinical decision making. Some years ago two Australian journalists Ray Moynihan and Melissa Sweet wrote an excellent book – Ten Questions you must ask your Doctor (Allen and Unwin 2008) and they are still as relevant today.
- · Do I really need this test
- · Do I really have this disorder
- · Do I really need to be screened
- · What are my options
- · How well does this treatment work
- · What are the side effects
- · Will this operation help – and by how much
- · What is the evidence on which we ( you the health professional and me the patient ) are basing these decisions
- · Who else is profiting here
- · What can I do to help myself
To these questions we might also add: what is it going to cost me and why do I need a pay a ‘gap ‘ (what is the justification for it ) and what is the ‘value ‘ of this test/ procedure).
So away consumers – and we all are – arm yourselves for these discussions – they may be hard but I suspect will improve your own health outcomes and prepare yourself and your health professional for the brave new world of shared clinical decision making and the rational health care debate which we have thus far managed to avoid.