In a sign of the general level of weirdness surrounding recent health policy debates, the AMA is calling on the Government to “put an end to the crazy policy speculation being floated in the media”.
So weird and worrying are the signs, in fact, that Dr Tim Senior is fearing zombie apocalypse. And yes, you read that correctly.
(By the way, if you haven’t already checked his Pozible campaign for a Wonky Health column investigating the health impacts of policies, please do.)
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Our health system is under assault by a zombie apocalypse
Tim Senior writes:
“I had this chest pain last week. I wondered if I should go to hospital, but I thought I’d check with you first.”
This is not something doctors ever like to hear from patients: the biggest killer with heart attacks is a delay between chest pain and treatment. A few hours makes a difference. A week is way too late.
There are various reasons people don’t go to hospital with something that could kill them. Sometimes they live too far away. Sometimes they don’t have transport. Sometimes they are worried that they’ll be accused of wasting their time.
Often they are worried about wasting their own time with long waits. They can expect cultural misunderstandings. Some are kept away by their previous experience of being told off or frowned at or openly abused.
Then I read that we might be deliberately adding cost to that list by charging people attending emergency who are deemed to be inappropriate attendees (also threatened in the UK NHS).
This is the ultimate health care zombie – “a daft policy that refuses to die.”
And it’s an apocalypse because it makes the health system cost more (PDF), but is no more effective.
Of course anyone turning up to an emergency department with a heart attack wouldn’t be charged.
But not knowing whether you might be charged will be enough to put off some people who should be there. A worry about cost is not going to speed someone’s journey to getting treatment.
And remember, those who worry most about cost will be those who are most likely to have a heart attack.
But what if it doesn’t turn out to be a heart attack causing the chest pain?
You’re probably OK if you had a clot go to the lung – financially anyway – but what if it’s a sprained chest wall muscle, or inflammation in the rib cartilages? Those should be seen in GP. Do they get charged?
Despite attempts to define inappropriate attendance, in fact, it turns out that there is no agreement about what is an appropriate attendance at an emergency department.
So who will make the decision? A clinical decision won’t be consistent. Will a hospital manager, a Medicare local manager or a politician be any more consistent?
What a policy like this forgets is that people don’t turn up to an Emergency Department with a diagnosis. They turn up as a person with a set of symptoms. They have a logical decision process and, interestingly, there is no relationship between lay and professional beliefs about what constitutes an emergency.
What drives them to seek medical help is anxiety. They are worried about the symptoms. So those symptoms that suggest a cold or flu are the same set of symptoms in early meningitis. That symptom of indigestion could be the first signs of a bleeding stomach ulcer.
Yes, it may well be more appropriate for people with those symptoms to go and see a GP (I’d argue they’d get much better service there) but you can’t discount the anxiety of people with worrying symptoms perhaps unable to get to a GP and with a complex health system to navigate.
I’ve never yet met anyone who attended the Emergency Department for fun, or as a cheap alternative to taking the kids to the zoo.
Just because Emergency Departments are busy doesn’t mean most of the people there shouldn’t be there. It turns out that those who use Emergency Departments the most aren’t those who should be at the GP.
And you won’t be surprised to learn that the reasons Emergency Departments are busy are more complex than just the fact that they are free.
Sadly, the limit of thinking about the health system in this policy seems to be “If we’re going to charge a co-payment for a seeing a GP, then we’d better charge for Emergency, too.”
Look again, though at those frequent users. Nearly 70% were already under the care of the hospital specialists. Over a quarter of those presenting had altered consciousness due to drugs or alcohol – a payment does nothing for those people, except deny them care, whereas broader action to tackle drugs or alcohol misuse might well have an impact.
Forty per cent of the people presenting were homeless. Think about that for a minute – Emergency Departments being a stop-gap in medical care for a large number of homeless people.
Does a charge sound like a solution to that problem? Or does it sound more like a large brush for sweeping something under a carpet?
Another study (with good figures and bad terminology about Aboriginal and Torres Strait Islander people) looked at the presentation of Aboriginal and Torres Strait Islander people to three Victorian Emergency Departments.
They found, perhaps unsurprisingly, that Aboriginal and Torres Strait Islander people lived in the poorest catchment areas, were less likely to nominate a GP and were more likely to leave either before being seen or before treatment was finished.
Can someone explain to me how charging will help these people – specifically how it helps in Closing the Gap? I can’t see it myself.
As a doctor, we have it drilled in to us not to use treatments that don’t work. We’re not supposed to use antibiotics for viruses, chiropractic care for asthma or colloidal silver for anything.
Co-payments for health care are just the same.
It might sound plausible that they save a health service money, but all the evidence shows that they don’t. They end up costing the health system more – you get less bang for your buck.
Sadly, like all zombies, and unlike my patients, this policy is very difficult to kill.
It just keeps on coming, eating away at the sustainability of our health system.
• If you found this article useful, please consider supporting Dr Tim Senior’s campaign to write a regular “Wonky Health” column for Croakey.
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Further reading
Meanwhile, Bond University’s Professor Chris Del Mar has also skewered the suggestion for copayment for GP consultations in an article in The Medical Journal of Australia.
He writes:
“A $6 copayment would undoubtedly deter some people who should visit a GP from doing so, thereby harming them, while others who can afford to pay would be barely inconvenienced. Although a copayment might save a little money in the short term, it would impoverish us all — not just by the downstream increase in specialised health care and the harm done by missed serious illness and missed opportunities to properly reassure patients, but morally as well.”
Emergency Dept’s free? Recently taken by Emergency Ambulance with suspected heart problem. Four hours in Emergency undergoing all “bells and whistles”. Discharged self . . partly dressed. Charged in excess of $200 cash! Am Pensioner. Ambo’s excellent; Emergency staff competent; Administration . . very well fed!! Cannot afford repeat performance.