Introduction by Croakey: As the Tokyo Olympics came to a close this week, global rankings of a different ilk came into focus with the release of the Commonwealth Fund’s health system analysis of high income countries.
The Fund’s 2021 report ‘Mirror, Mirror: Reflecting Poorly‘ looks at the performance of health systems across 11 advanced economies including Australia.
In this piece for Croakey, health policy analyst Charles Maskell-Knight takes a look at Australia’s performance, with access issues proving the difference in a race to the finish.
Charles Maskell-Knight writes:
The Commonwealth Fund has released its latest ‘Mirror, Mirror‘ report, comparing the performance of the health care systems in 11 high income countries.
It assesses performance across five domains: access to care; care process; administrative efficiency; equity; and health care outcomes.
Not surprisingly, it concludes that the US is the worst performer overall, despite spending almost 17 percent of GDP on the health system. The report also ranks Australia third overall, behind Norway and the Netherlands.
Before we give ourselves a collective pat on the back for our bronze performance, it is worth remembering that the ratings are quite volatile – apart from last place, which has been firmly held by the US for many years.
The make-up of the top three nearly always changes from edition to edition. But having said that, Australia usually performs well: fourth in 2014, and second in 2017.
It is also worthwhile looking at the results by domain to see where the Australian health system can be improved.
Process, access gaps
There is no doubt our system does well in care outcomes, and in the latest report Australia is ranked first in this domain.
We have the highest life expectancy at age 60 of any country in the group, and the second highest reduction in avoidable mortality over the past decade.
Australia also does well in equity, ranked first on the basis of the smallest income related disparities on a range of measures including affordability, timeliness, preventive care, safe care, and engagement and patient preferences.
We are still a broadly egalitarian country when it comes to healthcare.
The Australian system is ranked second in administrative efficiency behind Norway. The Medicare payment infrastructure may be ageing, but it is still incredibly cheap to run, and payments for public patients in public hospitals use clinical data which would have been collected in any case.
Our national performance is only let down by the private health insurers, with administrative costs of close to 10 percent of benefits paid.
We do not do so well on care process, where Australia is ranked sixth. This domain includes measures of coordinated care, preventive care, safe care, and engagement and patient preferences.
The system does poorly compared with others in:
- avoidable hospital admissions for diabetes and asthma
- sepsis following abdominal surgery
- pulmonary embolism following lower limb joint replacement
- mammography screening
- EDs communicating with GPs
- GPs communicating with home care and other community providers, and social services.
The Australian system’s worst performance is in the access to care domain (including affordability and timeliness), where we are ranked eighth.
In relation to affordability, in the last year:
- 21 percent of people reported a cost-related access problem
- 32 percent had skipped dental care because of cost
- 17 percent had insurers deny claims or pay less than expected
- Nine percent had serious problems in paying medical bills, and
- 28 percent had out-of-pockets of more than $US1000.
The system does a little better in timeliness, although the 69 percent of GP practices that have after hours arrangements in place (other than referral to an emergency department) is lower than France, Germany, the Netherlands, New Zealand, Norway, Switzerland, and the UK.
Out of pocket, out of reach
The findings on affordability reflect the narrow scope of Medicare, shortcomings in private health insurance, and the lack of price restraint by some doctors.
One of the great failings of Medicare is that it does not cover dental care, while cover for other non-medical interventions is extremely limited. The 40 percent of the population that cannot afford private health insurance but do not quality for public dental schemes directed to the indigent have to pay out-of-pocket for all dental care.
For people with private health insurance, the average benefit paid for extras cover is about half of the fee charged, and there are annual limits on total benefits.
Medicare and the PBS will subsidise a GP to prescribe pain relief for a bad back, but generally won’t pay for the physiotherapy to address the underlying cause. (Yes, there are physiotherapy items for people with chronic illness and complex care needs under a Team Care Arrangement or equivalent, but these should not be available to people who are otherwise healthy. And there is a limit of a total of five attendances a year across a range of allied health professions, and the schedule fee is about half of the market rate.)
The Commonwealth Fund report states that while 24 percent of lower income Australians reported a cost-related access problem in the last year, so did 19 percent of higher income people. This finding is likely to reflect high and uninsurable medical gaps.
APRA data for the May quarter shows that for hospital episodes, plastic/reconstructive surgeons (not cosmetic) charged 69 percent more than the combined benefit from Medicare and private health insurance.
Figures for other specialties include 39 percent for ENT, 35 percent for urology, 32 percent for orthopaedics, and 24 percent for anaesthetics.
And these are averages, with a long tail to the right.
We should acknowledge that our health system does well at a global level in achieving good health outcomes, and is reasonably fair.
But we should not forget that many people still face significant problems in accessing care due to financial pressure.
Rather than treating the health system as “set and forget”, policy makers need to develop responses to the evident problems to lift us to a gold medal.
Charles Maskell-Knight, a former senior public servant in the Commonwealth Department of Health for over 25 years, contributes regularly to Croakey.
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Thanks Charles,
I think the high ranking for equity is a bit too simplistic. 19% of higher income earners state cost as a barrier to access, whilst 24% of lower income earners do. I think the comparison between the two groups needs to consider where the barriers are and you did talk to that. For low income earners they would be mainly costs for PBS subsidised drugs , copayments to see doctors especially specialists, and copayments for allied health. For high income earners who wish to have private (publicly subsidised) care the barriers would mainly be the gaps between insurance payments and doctors fees, and non subsidised drugs. Thus, low income earners don’t dream of private specialist hospital care but might try private specailist outpatient care. The inequity is much more stark than is charted.
In addition the only measure of equity was the above comparison of cost barriers. Inequities in timeliness of care should also be considered given our very long waiting lists for public outpatients and inpatients. This may well be reflected in Australia being rated 8th out of 11 for access to care ( no comparison between income groups), but sufficiently low rating I think to indicate that given higher income earners are likely to access care reasonably quickly, it is the lower income earners timely care or lack thereof which pulls our rating down so low.
Thus I conclude that our star rating for equity is false.