Introduction by Croakey: At our election webinar this week, the gap between what Australians seem prepared to pay via taxation to support health and other services, and the costs of providing such services was one of the topics up for discussion.
Health policy analyst Charles Maskell-Knight questioned whether Australia could claim to have a universal healthcare system when many people cannot access services, depending upon where they live and the out-of-pocket charges involved.
“There are so many areas where more Government expenditure would make a huge difference to peoples’ lives,” he said. “As a nation we seem to be satisfied with the idea that if you are old, if you are sick, it’s up to you to pay more, [that] it’s not up to us as a nation, as a people to pay more collectively – and I find that really sad.”
While the two major parties have pitched election policies aimed at reducing the costs of some medicines, there are no such promises of systemic reforms to address the wider problem of out-of-pocket costs (a concern covered extensively by Croakey in recent years). These are particularly significant for people seeking care from specialists.
At a time of increasing cost-of-living pressures, the consequences include that many Australians will choose to spend their money on food, housing and petrol rather than healthcare, warns Anthony Scott, Professor of Health Economics at the University of Melbourne. His article below was first published at The Conversation.
Anthony Scott writes:
Rising out-of-pocket costs for health care is an important issue the major parties have not yet substantially addressed during the election campaign.
We heard just this week how healthcare costs are rising faster than other costs of living pressures. Healthcare costs are also rising faster than wages. The rising cost of specialists’ fees, in particular, are a concern. So, many Australian families are finding it increasingly difficult to keep up.
Earlier this year, a major consumer survey found 30 percent of people with chronic conditions were not confident they could afford needed healthcare if they became seriously ill; 14 percent could not pay for healthcare or medicine because of a shortage of money.
Out-of-pocket costs are rising
Out-of-pocket healthcare costs cover a range of expenses not covered by Medicare or private health insurance, such as doctors’ fees for consultations and surgery.
Only 35.1 percent of specialist consultations were bulk billed in 2020-21 compared with 88.8 percent of GP services.
For private (multi-day) hospital care in 2019-20, 43.7 percent of separations (hospital admissions that include procedures and operations) had no hospital or medical out-of-pocket cost.
Out-of-pocket costs are rising, Medicare statistics show.
There is ample evidence out-of-pocket costs reduce access to, and use of, healthcare. This more strongly affects people who need healthcare the most.
For instance, access to timely specialist care in Australia depends on your income and ability to pay.
Although richer people use more specialist care, on average, it is less-affluent people who have higher need for healthcare. Yet it is less-affluent people who have to wait to see a specialist in a public hospital.
High doctors’ fees have other consequences. They may provide skewed incentives to doctors, leading to overdiagnosis and overtreatment. Doctors may also flock to high-earning specialties while we have a shortage of GPs (who are paid half as much as specialists).
What do the major parties promise?
Health policies announced by the major parties ahead of the federal election do not necessarily translate into lower out-of-pocket health costs, or focus on the most pressing issue.
The Coalition has promised to lower the safety net threshold for the Pharmaceutical Benefits Scheme. This announcement, made in this year’s federal budget, would make medicines cheaper or free for people who need multiple scripts a year.
But this is an area where out-of-pocket costs have been falling for some time compared with other areas of spending. So any announcement may have been better targeted at areas where out-of-pocket costs are growing more quickly.
In any election there is always a focus on access to GPs and bulk billing. This includes Labor’s proposal for new urgent care centres, which would provide bulk billed services to take the pressure off emergency departments.
However, neither of the major parties are doing anything about the continuing and much larger increases in specialists’ out-of-pocket costs.
Can informed patients make a difference?
The Coalition introduced a price transparency website in 2019 that provides estimates of out-of-pocket costs for private hospital care, with plans for doctors to voluntarily upload their fees. Some private health insurers also have such websites.
However, these websites rely entirely on consumers doing the “leg work” by shopping around to reduce their out-of-pocket costs. The assumption is that by providing consumers with more information, they will make better choices. But this is too simplistic because information can difficult to get and understand, and these websites don’t include data on the quality of care.
Our review on price transparency websites in health care shows they may not work for consumers. Not all consumers can or want to use them. There’s also the risk doctors could use these websites to see what other doctors are charging and increase their fees.
It could be better if these websites were used by GPs when referring patients to specialists. Patients can also be encouraged to ask about the out-of-pocket cost when booking an appointment or during the visit.
But this does not help patients who are usually in a vulnerable position, who want care quickly, do not have the information or time to shop around, and might think the care they receive will be affected if they ask about cost.
Can doctors make a difference?
Doctors set their own fees and many use the Australian Medical Association fee schedule as guidance. They decide what fee to charge, whether to bulk bill, or whether to use gap cover provided by private health insurers for private hospital care.
At the moment it would require a brave politician to directly control doctors’ fees given the constitutional protections they have and the way Medicare and private health insurance were designed to provide subsidies to patients, not to directly pay doctors.
However, something the major parties can address is “bill shock”. Patients don’t always know the doctor’s fee before they visit, and in some circumstances don’t know in advance how much a procedure will cost.
If care involves many tests, visits and procedures over time by different doctors, then there will be a bill for each. This shifts all the financial risk to patients, something private health insurance was designed to handle.
At a minimum, doctors’s fees and out-of-pocket costs need to be bundled together and published as an upfront quote or range for the expected course of care. This is something that could be addressed by one of the major parties.
Addressing rising out-of-pocket health costs is a complex area linked closely to broader reform of the healthcare system, which neither major party has promised to do anything about.
Without such reforms we’ll see Australians prioritising spending on food, housing and petrol over healthcare, in the current climate.
But Australia cannot afford to allow this to happen. As we have witnessed during the pandemic, an unhealthy population is not only bad for individuals, it’s bad for us all.
Anthony Scott is Professor of Health Economics at the University of Melbourne. Disclosure statement: He receives funding from a research grant awarded by the Medibank Better Health Foundation on out of pocket costs and price transparency.
See Croakey’s archive of articles on out-of-pocket costs.