Croakey is closed for summer holidays and will resume publishing in the week of 13 January 2025. In the meantime, we are re-publishing some of our top articles from 2024.
This article was first published on Thursday, October 10, 2024
It’s shocking that initial findings from the Senate Select Committee on the Cost of Living do not mention healthcare costs, according to health policy analyst Dr Lesley Russell.
However, her latest column puts a strong focus on out of pocket costs, including potential solutions. While the Greens have unveiled a plan they claim would address the lack of access to and affordability of primary care, the reality is that the plan is “pie in the sky”, Russell writes.
Her latest column takes a deep dive into prevention and primary care reform, with a focus on chronic disease management, climate change and maternal health, and infectious diseases, and also brings some heart-warming news on night parrots.
The quotable?
[Progress on primary care reform] is not helped by the professional medical organisations (or, as my colleague Charles Maskell-Knight calls them, the medical unions).
They seem to have lost any appetite they ever had for real reform and are now only interested in increased financial support for fee-for-service.”
Lesley Russell writes:
The Health Wrap is back after a brief sojourn while I took a quick trip to Aotearoa/New Zealand.
The area around Queenstown in the South Island is one of my favourite places – rugged, snow-capped peaks reflected in the waters of Lake Wakatipu, lush beech forests with masses of ferns and mosses, roaring rivers that are aquamarine due to glacial flow, lots of bird life and some great hiking.
Addressing out of pocket costs
The media has recently been covering the rising cost to patients of using the healthcare care system – seeing a GP, a specialist, a dentist, or an allied health professional or having surgery or maternity care in private hospitals.
See, for example:
ABC News: The hidden costs of raiding super to pay for healthcare
ABC News: Australians delay dental care and remain on long public wait lists, leading to more in hospital
The Medical Journal of Australia: Cost barriers to medication access in Australia: an analysis of the Patient Experience Survey in context
See also the Health of the Nation 2024 report from the Royal Australian College of General Practitioners.
Out of pocket costs are also seen as a major reason why people are not choosing private hospitals for their care.
These are not new problems – but the costs are burgeoning at a time when the cost of living is restricting people’s spending, and as a consequence, many people are foregoing preventive services and delaying needed treatment.
The Albanese Government has tripled bulk billing incentives for pensioners, children and healthcare card holders, and this has seen an increase in bulk billing rates for these population groups, but patients who don’t qualify for bulk billing incentives are paying more.
It’s worth noting here that the Senate Select Committee on the Cost of Living, which was established in September 2022, has yet to report. The reporting date, originally set for 30 November 2023 has been extended twice; the reporting date is now 15 November 2024 (and the submission closing date is now 30 October 2024).
Shockingly, none of the findings and recommendations from the first interim report (May 2023) and the second interim report mention healthcare costs. A quick glance at the submissions suggests that the Select Committee has heard little on this matter.
Doctors’ groups argue that Medicare rebates are insufficient to meet the actual cost of providing care, and that is undoubtedly correct. But the fact is we know next to nothing about the costs of operating a private medical practice.
The Royal Australian College of GPs (RACGP) has selectively released data from their latest Health of the Nation report that shows:
- One in four GPs say they are bulk billing more consults since the incentive payments were introduced (which begs the question about why the other 75 percent of GPs have not increased their bulk billing).
- For patients who are not bulk billed, the average out of pocket cost for a 20 minute consult is now $36.86, up from $34.91 in 2023.
The RACGP President, Dr Nicole Higgins, compares this increase (almost six percent) to the costs of running her practice (6.1 percent). She is now calling on the Federal Government to increase Medicare rebates for 20-minute and longer consults by 20 percent, with additional increases for rural and remote communities.
Whatever you think about that argument, Dr Higgins is correct when she states that Medicare, when it was first designed 40 years ago, was intended to cover 85 percent of the cost of providing care and it’s now less than 45 percent in general practice. What she doesn’t say is that patients are covering the gap (and in some cases, more than the gap).
The out of pocket costs situation is even worse when it comes to speciality care. The Australian Institute of Health and Welfare says that Medicare now only covers 52 percent of specialist fees for office appointments (this does not include surgical costs). I’m intrigued that – given the size of the patient payments – this figure is more than for general practice!
Patients paid $2.3 billion in out of pocket specialist fees in 2022-2023. The situation is particularly bad for obstetrics: the National Association of Specialist Obstetricians and Gynaecologists (NASOG) says Medicare covers just 39 percent of obstetric costs.
A recent article in The Conversation looked at why specialist fees are so high. The author, Dr Susan Mendez, has co-authored a study that finds fees varied significantly between specialists in the same field. In some cases the most expensive specialist charged more than double what the cheapest one did.
Intriguingly, this work found that specialists who score more highly on agreeableness are more likely to accept the government subsidy as full payment, while those who score more highly on conscientiousness and neuroticism are less likely to do so.
It’s not surprising that specialists who are practice owners tend to set higher fees and bulk bill a smaller proportion of patients.
Those treating more complex patients charge higher fees, but also bulk bill at a higher rate, which could be due to more complex patients having high healthcare expenditures and that doctors are aware of this.
These findings beg the question of how appropriate and reasonable it is for patients in financial distress due to medical costs to rely on the altruism or agreeableness of doctors for some alleviation of their costs.
We must all acknowledge that for some time now Medicare has ceased to be a universal healthcare system, where people pay in according to their means and are treated according to their needs.
In August Health Minister Mark Butler said, with reference to GP bulk billing rates, “We are starting to see those green shoots of recovery.”
More recently he said: “The private health sector, including insurers and specialists, need to do more to protect patients from exorbitant bills.”
Over the years, my Croakey colleague Jennifer Doggett and I have made a number of suggestions about how out of pocket costs might be addressed.
See, for example, A road map for tackling out of pocket health care costs and Out of pocket costs: a wicked problem in search of solutions.
The Grattan Institute has also put forwards a number of papers addressing these issues:
- Not so universal: how to reduce out of pocket healthcare payments
- How Australia should fill dental and budget cavities.
The Grattan Institute’s Health Director, Peter Breadon, has proposed solutions to the problem of the cost of specialist care that include boosting the supply of specialists, expanding public care for people who cannot afford private fees, and increasing transparency around how much specialists charge.
He argues a rebate increase in isolation would likely not help. “In the past when rebates have gone up, patient fees haven’t actually gone down,” he said. “There are some deeper structural problems that have to be addressed here.”
Last week the Greens – flush with potential funds from their proposal to introduce ‘Robin Hood’ tax reforms – unveiled a plan they claim would address the lack of access to and affordability of primary care.
If fully implemented, the plan might well do that. But the reality is it is pie in the sky – dependent on the Greens being part of the next (minority) Labor Government, of getting all the billions of dollars needed to fund this effort, and – crucially – having the necessary workforce.
The Greens’ “GP for Free” plan (for a total of about $54.2bn out to 2034-35) includes:
- 1,000 free local healthcare clinics – six clinics per federal electorate. I assume these would look like Labor’s Urgent Care Clinics, although apparently they will include dentists and psychologists. This has tentatively been costed by the Parliamentary Budget Office (PBO) at $3.7 billion over the first four years.
- An extension of the tripling of the GP bulk billing rate (as currently for pensioners, children and concession card holders) to all Medicare card holders and a 20 percent increase to the Medicare patient rebates for all GP level C and D (longer) general attendance items. This would cost around $5.8 billion over the first four years (it’s not clear if this includes indexing).
- A program to ensure that GPs in training would be paid the same as hospital (non-GP specialist) trainees, to cost $100 million per year.
There’s not much detail on the Greens’ website. See here and here. I got more information from an article in The Guardian here and ABC News here. The PBO costings are here and they provide some further details.
Primary care reforms
At the heart of the wicked problems outlined above is the equally wicked issue of primary care reform. This is a commitment from the Albanese Government, but – as I have frequently bemoaned – progress is painfully slow, sometimes hard to discern.
It’s not helped by the professional medical organisations (or, as my colleague Charles Maskell-Knight calls them, the medical unions). They seem to have lost any appetite they ever had for real reform and are now only interested in increased financial support for fee-for-service.
Their outrage over Urgent Care Clinics exemplifies this. Of course, it would be best if everyone had a designated GP – one they could always see in a timely fashion and with minimal cost. But bulk billing GPs are hard to find; even harder to find is a GP surgery open after hours and on holidays.
Urgent Care Clinics provide the services people need and they are very popular. And they cost less that an Emergency Department visit, the only other alternative for many Australians.
A key issue for primary care reform is the support that patients and primary care providers need to better manage chronic conditions.
Currently the main vehicles for this are the Medicare chronic disease management items, which have been in place since 2005. These allow GPs to develop management plans (this should be done in consultation with patients) that include a limited number of allied health referrals and provide for team care arrangements. Further information about the operation of these plans is here and here.
The problem is that we know little about how effective these plans and arrangements are in helping patients to better manage and coordinate care for their chronic conditions. The most recent data on use of the chronic disease management items on the website of the Australian Institute of Health and Welfare are from 2019.
I am not aware of any official evaluation of these Medicare items, although there are some peer-reviewed papers. Here is a brief summary of the papers I found:
- A number of studies have demonstrated substantial positive changes for health professionals and patients but measuring and achieving positive clinical health outcomes is difficult (reference here).
- There are barriers to patient engagement in chronic disease management plans (reference here).
- It is good to see that people with diabetes and individuals with the greatest need based on health, socioeconomic and lifestyle risk factors are most likely to use these Medicare items. However only a fraction of Australians eligible for chronic disease management items use them (reference here).
- In people with or at elevated risk of cardiovascular disease, GP Management Plans are under-utilised and are not associated with improved risk management (reference here).
I was intrigued to discover a paper, published in the Australian Journal of General Practice in July, that looked at the business case for using these Medicare items for cardiac rehabilitation.
This is important for two reasons: firstly, rates of patient uptake of cardiac rehabilitation are low, especially in rural Australia, and secondly, we know so little about business models in general practice. But it also makes me nervous to think that practices might implement patient care and coordination services on the basis of financial benefits to the practice rather than healthcare outcomes for the patient.
The General Practice and Primary Care Clinical Committee of the MBS Review Taskforce recommended specific changes to the General Practitioner Management Plan and Team Care Arrangements Medicare items. This report was published in December 2020.
I wrote an article for Pearls and Irritations about these recommendations, The recommendations from the MBS Review for reforms in primary care: who will ensure these proposals are properly considered? when the preliminary report from the Committee was released in December 2018.
Most of these proposed changes have now been put forward for implementation. These involve:
- ReplacingGeneral Practitioner Management Plan and Team Care Arrangements with a single GP Chronic Condition Management Plan.
- Requiring patient enrolled in MyMedicare to access management plans through the practice where they are enrolled. Patients who are not enrolled in MyMedicare can access management plans through their usual GP.
- Financial incentives to encourage reviews of management plans.
- Formalised referral processes for allied health services.
I have been unable to establish what, if any, consultation was involved in developing these changes. Clearly not enough. These changes were to come into effect from 1 November, but the RACGP has complained about lack of information and (perhaps more significantly) lack of funding and concern about financial losses.
So now these changes have been deferred until 1 July 2025.
Meanwhile, on 20 August 2024, the MBS Review Advisory Committee commenced a review of MBS allied health chronic disease management services. This could bring further changes for the Medicare chronic disease management items.
A stronger focus on prevention
In the United Kingdom there is great concern about the need to revitalise the National Health Service. Some interesting proposals are being put forward that could be considered (in context) for Australia.
A recent series of three papers from the non-government educational charity, Reform, looks at prevention as a new model for primary care. These are oriented around three core principles: to intervene earlier, respond faster, and avoid decline – all supported by a new technology infrastructure and new funding mechanisms.
The funding model reflects three key principles that are lacking here and would make good sense to consider: incentivise outcomes rather than activity; focus on population groups rather than disease pathways; and enable long-term planning.
A recent paper, published in the Australian and New Zealand Journal of Public Health, finds that Australia spends less than $140 per person per year on preventive health – three times less than several comparable countries. The amount varies among States and Territories. For example, the Northern Territory spent $527 per person on public health, while Victoria spent just $110.
Less than two percent of total Government health spending goes towards public health efforts like infectious and chronic disease protection, prevention and health promotion.
There is also a lack of transparency in exactly how much and where public health money is spent and a failure to measure its cost-effectiveness.
As pointed out by the CEO of the Public Health Association of Australia, Adjunct Professor Terry Slevin, there is no annual reporting of spending on preventive health in Australia, and no major national report has reported on funding on public health for over a decade.
It’s time to give more than lip service to efforts to address the prevention of chronic illnesses.
To round off this section: I recently found a research paper in Health Affairs that looks at the return on investments in social determinants of health interventions, specifically food and housing security.
The average Return on Investment (ROI) for food insecurity programs was 85 percent, and for housing insecurity it was 50 percent.
And a report from the UK King’s Fund on how public health and population health leaders can work together in the emerging health and care context:
Growing threats from infectious diseases
Marburg virus disease
Rwanda is in the midst of an outbreak of Marburg virus disease, a haemorrhagic fever with a high fatality rate that has killed at least 13 people there this year.
There is no proven vaccine or treatment for infections with the virus, which is closely related to Ebola virus and causes similar symptoms.
The outbreak, which was declared on 27 September, is Rwanda’s first. Tanzania and Equatorial Guinea had Marburg outbreaks last year, and Ghana in 2022.
Researchers say that environmental threats, such as climate change and deforestation, make it more likely that people encounter animals that can pass on infections.
Rwanda is recognised as having a good public health system, so there are hopes the outbreak can be contained. With support from the Africa Centers for Disease Control and Prevention, the Rwandan government is implementing rigorous testing, contact tracing and quarantine measures to contain the outbreak.
But there are concerns that the healthcare system could become overwhelmed by the deadly Marburg virus because most of those infected are medical professionals, and some have already died.
A clinical trial of a vaccine candidate from Sabin Vaccine Institute is underway following the delivery of about 700 doses requested by the Rwandan government.
Polio
We are seeing a global revival of polio, a disease once close to being eradicated.
Pakistan, one of only two countries in the world where the virus remains endemic, had seemed on the verge of defeating polio, with no new infections for a little over a year starting in 2021 – the longest virus-free stretch the country had ever experienced.
But since then, polio has roared back, spreading beyond its traditional hot spots to areas once largely untouched by the virus. In early September, health officials reported the first polio case in the capital, Islamabad, in 16 years.
In response, Pakistan has undertaken a nationwide polio vaccination campaign involving 286,000 health workers – the largest public health surveillance network in the world – aimed at vaccinating 30 million children under five.
The virus has also returned to Kandahar in the south of Afghanistan, the other country where it is endemic. The number of paralytic polio cases remains relatively low because much of the population has been immunised, but circulating virus is a threat to any unvaccinated or under-vaccinated child.
The war in Gaza has seen concerns about the threat of infectious diseases because of mass displacements, the unsanitary conditions in which people must live, and the disruption of medical services. The Gaza Strip had been polio-free for 25 years but now the polio virus has been found in water samples and one baby has been found to have been infected with the virus.
Over 187,000 children under ten years of age were vaccinated with novel oral polio vaccine type 2 (nOPV2) in central Gaza during the first phase of a two-round polio vaccination campaign, conducted between 1–3 September 2024. Continued hostilities threaten the ability to conduct a second round of childhood vaccinations.
Antimicrobial resistance
Elsewhere around the world there are threats from H5N1 bird flu in the United States, West Nile virus in the Caribbean, and Mpox on several continents. These come at a time when the effectiveness of many antibiotics, antivirals and antifungals is undermined by growing antimicrobial resistance.
Last month The Australian carried a news story about a Ukrainian soldier whose leg was amputated because doctors could not treat his infection.
An initial cocktail of five different antibiotics failed to kill the bacteria that he had picked up in hospital. Four other drugs were tried, including colistin, a “top-shelf” antibiotic with severe side effects that is reserved for cases where nothing else will work. In the end, the only way to save the soldier’s life was to remove the infection by amputation.
At the United Nations General Assembly last month the World Health Organization called for urgent, high-level action to address the global scourge of antimicrobial resistance.
The 28 September edition of The Lancet has a number of articles on what the editorial describes as “a global public health emergency that requires concerted efforts by all stakeholders”.
In Australia, the trends observed in national surveillance of bacteria with critical antibiotic resistance are very concerning.
According to the latest data from the National Alert System for Critical Antimicrobial Resistances (CARAlert), 2023 saw an 86 percent increase in critical antimicrobial resistances compared to 2022. The majority were detected in hospitals (62 percent), with a smaller proportion identified in community settings (38 percent).
A recent survey showed that one in every ten children in Australian hospitals with a bloodstream infection are infected with a multi-drug resistant organism.
Climate change and maternal health
A report recently published by the Journal of the American Medical Association (JAMA) shows that there were more than 21,500 heat-related deaths recorded in the United States between 1999 and 2023, an increase of 117 percent.
That trend is expected to increase substantially by mid–21st century (2036-2065), with a disproportionately large increase in extreme temperature–related deaths projected for older, non-Hispanic Black, and Hispanic populations.
An article from Center for American Progress highlights how climate change is especially threatening to the health and safety of pregnant women.
Extreme heat increases pregnant women’s risk of severe maternal morbidity, life-threatening pregnancy complications, and maternal mortality. It’s also been shown that stillbirths increase around five percent for every one degree Celsius rise in temperature. This link is particularly strong in the last month of pregnancy.
“Climate change is a growing threat to maternal, newborn and child health that can no longer be ignored,” the WHO said in a statement issued last November.
Researchers who studied almost a million mothers in New South Wales found a 16 percent higher risk of having a pre-term birth for those living in the top five percent hottest parts of the state. Other research from Western Australia found extreme heat can affect a baby’s birth weight, which is a key determinant of a child’s future health.
Clearly this issue is of particularly concern for Aboriginal and Torres Strait Islander women who live in remote communities in the far north.
Good news on Indigenous health
Last week saw the establishment of a new National Commission for Aboriginal and Torres Strait Islander Children and Young People.
As I celebrate this, it’s also important to note another big move in this space that happened last month as part of National Child Protection Week.
Founding members of Allies for Children, an umbrella organisation that includes Act for Kids, Barnardos Australia, Life Without Barriers, OzChild, Mackillop Family Services, Key Assets and the Benevolent Society, have committed to having Aboriginal Community Controlled Health Organisations (ACCHOs) take the lead with Indigenous children in out-of-home care as a way of connecting them back to community.
Catherine Liddle, the chief executive of SNAICC, called this a bold first move – ACCHOs are recognised as providing the best outcomes for families and children. “They have greater successes in reunifying Aboriginal and Torres Strait Islander children with family, because they are an intrinsic part of community.”
Best of Croakey
As elections loom in Queensland and in the ACT, Croakey does a great job of keeping all Australians up-to-date with the issues:
- What the Aboriginal Community Controlled Health sector wants this Queensland election
- As the Queensland state election looms, here are the public health issues at stake.
And with the seminal US election also looming (on November 5), here’s a reminder of how important the right to vote is, to democracy, to social justice and to health equity – from an article in Health Affairs: Voting Is Critical To The Pursuit Of Health Equity.
See the Health and Democracy Index here.
Another good news story
There have been some great stories about how the Indigenous Rangers on Ngururrpa Country are working to save the critically endangered night parrots.
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.
Previous editions of The Health Wrap can be read here.
