Health Policy, Administration and Expenditure

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1 Submission to the Parliament of Australia Senate Community Affairs Committee Enquiry into Health Policy, Administration and Expenditure September 2014

2 Introduction The Australian Women s Health Network thanks the Senate Community Affairs Committee for the opportunity to make a submission on health policy, administration and expenditure. The submission will specifically address the following terms of reference: the impact of additional costs on access to affordable healthcare and the sustainability of Medicare. the impact of reduced Commonwealth funding for health promotion, prevention and early intervention. health workforce planning. The Australian Women s Health Network (AWHN) The Australian Women s Health Network is a health promotion advocacy organisation that provides a national voice on women s health, based on informed consultation with members. Through the application of a social view of health, it provides a woman-centred analysis of all models of health and medical care and research. It maintains that women s health is a key social and political issue and must be allocated adequate resources to make a real difference. It aims to foster the development not only of women s health services but of stronger communitybased primary health care services generally, which it sees as essential to improve population health outcomes. It advocates collaboration and partnership between relevant agencies on all issues affecting health. To this end, AWHN coordinates the sharing of information, skills and resources to empower members and maximise their effectiveness. The coalition of groups that comprises the organisation aims to promote equity within the health system and equitable access to services for all women, in particular those women disadvantaged by race, class, education, age, poverty, sexuality, disability, geographical location, cultural isolation and language. AWHN has representatives from across Australia in all States and Territories with a membership base of 153 organisations and individuals The impact of additional costs on access to affordable healthcare and the sustainability of Medicare Additional healthcare costs restrict access to those most in need of these services leading to longer term poorer health outcomes and low income earners being tipped into poverty through illness or injury. Significant increases in user fees and co-payments for healthcare has an even greater impact on women, as women up until retirement age visit the doctor more frequently than men (1) and are 2 P age

3 more likely to have carer responsibilities. According to the 2009 ABS Survey on Disability 71% of primary carers were reported as being women. Carers were reported as less likely to have private health insurance compared to women without carer responsibilities (Eager et al., 2007). There is considerable evidence to show that the cost of a service is a major barrier to access especially for low-income people (reviewed in Gray 2004:65 77). This has a flow on affect as it is widely known that people will delay or avoid visiting a GP, getting a prescription filled or accessing other medical tests (particularly diagnostic tests) when the overall cost of healthcare is no longer considered affordable (2). Medicare was introduced in Australia in 1984 to improve access to affordable medical care for all Australians. As well as providing point of service free treatment in public hospitals, a key feature of the system has been to provide access to affordable medical services and refunds for some medical expenses through a GP bulk billing system. This is to avoid a cost to patients at the point of service. The difficulty for Australians is that these costs have increased continuously since 1984 and are now some of the highest in the world (Schoen et al., 2010:2327). We frequently hear Medicare services referred to as free medical care. This is a serious misrepresentation of the fact that all Australians pay for Medicare through a universal tax based on income so designed to make the payment by individual taxpayers equitable. Free at point of service is not free. Even this is very rarely the case. People living in rural and remote areas, where services of most types are in short supply, face additional out-of-pocket costs. This is primarily due to shortages of bulkbilling GP s, distances to travel for health care causing less flexible appointment times and reduced access to public or community transport. A study conducted by Dobson et al (2003) identified a correlation for rural women in relation to the number of bulkbilling clinics and the rate at which the clinic charged. The study found that the rates of bulkbilling were lower and declining in rural areas but out-of-pocket costs had increased. This indicated that the increased expenditure in gap payments were as a result of increased health care costs charged by the clinics. Additional costs have a major impact on consumers ability to access health care which in turn leads to longer term poorer health outcomes. In 2009, 22 per cent of Australians went without care because of cost, 21 per cent paid user charges of $1000 or more and 8 per cent reported being unable to pay medical bills or having serious problems paying (4). This is especially the case for women, low income people and the aged due to the high cost of accessing both GP and primary allied health care services (psychologists, counsellors, physiotherapists, dieticians, dentists, optometrists, ambulance services, alternate practitioners) and the fact that these groups visit a doctor more frequently. Out-of-pocket expenses and co-payments even where safety nets are in place, mean that Australians on low incomes will continue to use fewer services than they need (Blendon et al 2002). Making the safety net less accessible will increases the likelihood of this happening as low income earners can be tipped into poverty through illness or injury. 3 P age

4 The threshold at present and the increase threshold for non-concession card holders are still inequitable as there are many low income earners without concession cards. The eligibility thresholds for Commonwealth concession cards are generally very low incomes, so the working poor are still on low incomes, and will be most affected by increases in these areas. Delaying access to health care services frequently leads to receiving medical attention in a crisis situation (5). This has a significant impact on the both the cost of service provision and the service provision response required in dealing with more complex health conditions and medical issues. When the cost of primary health care prevents people from accessing services, the principle of providing appropriate and cost effective health care is diminished. The most significant challenge for the ongoing sustainability of the health system is the ability to ensure quality services are available to all citizens at an affordable price. This can be achieved by addressing the structural barriers entrenched in the Australian healthcare system. Some of these include a reduction in user charges, increased access to allied health services and investment in social and biomedical research. Strengthening preventative health initiatives and support services and increasing access to affordable treatment services will assist to improve longer term health outcomes for all Australians and thereby increase the sustainability of the health system. The impact of reduced Commonwealth funding for health promotion, prevention and early intervention The current payment structure for GP services is fee for service and where the user pays, which works against the provision of preventative, primary health care. This model discourages longer appointments that are required for more comprehensive health assessments and for the management of complex and chronic conditions. The leading cause of death in Australia in 2011 was ischaemic heart disease (6). More than half of all GP consultations in Australia are in relation to a range of preventable chronic conditions such as heart disease, diabetes and cancer (7). There are numerous effects of co-payments on other parts of the health system. Some of these include reducing access to health services, delays in seeking medical attention, costs of medication, costs and access to diagnostic services and failure of people to seek treatment and follow up. The Medicare rebate covers five allied health sessions per patient in a calendar year (it is not possible under any circumstances to receive additional services). Few providers accept the Medicare payment as full payment for the service leading to out-of-pocket costs as people pay the difference between the fee charged and the Medicare rebate. Those who are most socio-economically disadvantaged are twice more likely to have a long-term health condition than those who are the least disadvantaged. Improving the health profile of Australians of working age in the most socio-economically disadvantaged groups would lead to major social and economic gains, with savings to both the Government and to individuals. 4 P age

5 The first National Women s Health Policy (DoHA 1989) found that women wanted equitable access to health care services which were preventive in orientation as well as geared to the treatment of diseases. A clear preference was found for moving towards a system with a preventive approach, with increased emphasis on innovative community-based services to complement those provided by general practitioners. A stated goal in the 2 nd National Women s Health Policy (Commonwealth of Australia 2010), is to ensure that the health system has a clear focus on illness prevention and health promotion. If prevention and disease management were more accessible for low-income working-age adults in Australia, 500,000 socio-economically disadvantaged people could avoid long-term chronic illness, $2.3 billion could be saved in annual hospital costs and the annual number of taxpayer-funded Pharmaceutical Benefits Scheme prescriptions could be cut by $5.3 million (NATSEM 2012). Health workforce planning While the number of women in the health system workforce is substantially greater than men, they hold a paucity of executive positions (management and governance levels) which are predominantly held by men. To redress this imbalance, the South Australian Government has set targets for all boards and committees to comprise 50% women by 2014, providing an example for all other jurisdictions. In the medical workforce women constitute a small proportion of specialists. The majority of medical practitioners are male, although the number of female doctors in the workforce has steadily increased to 36% of all working doctors (AFMW 2012). Similar to other professions, women in medicine are more likely to work part-time to accommodate family and caring responsibilities, and are less likely to own their own practice (PC 2005). Nonetheless, they also have longer working lives in their chosen profession. The nursing profession is 92% female, and women also constitute the majority of people working in community service organisations. In , women represented 84% of workers in community service industries, compared with 45% of workers in all other industries; in the Child Care Services industry, 96% of those employed are women; in the Residential Care Services industry, women comprise 86% of workers; while in the Social Assistance Services industry, three-quarters (75%) of those employed are women (ABS 2011). The allied health professions, for example, podiatry, optometry, social work, occupational therapy, speech therapy, dietetics, physiotherapy, are 80% female. However, women in nursing, occupational therapy, physiotherapy, social work, speech therapy and dietetics are more likely to exit the profession before the age of 50 years than people employed in less female-dominated occupations (defined as < 50% female). Optometry, general practice and dentistry have a higher initial retention rate of over 85%, which stays above 68% until age 55 years. In contrast, social work, dietetics and complementary medicine have a flatter pattern across the age range, with retention rates never exceeding 43% (Leach, Segal and May 2010). Recruitment and retention of a highly trained workforce are critical issues for health systems. Investment by government in the health workforce is undermined by workplaces and health workforce policy that are not sensitive to the needs of women. Those needs are likely to include the juggling of career and domestic responsibilities. Gender analysis of workforce policy is generally 5 P age

6 missing, as it is from the vast majority of health related policy. The development and adequately funded implementation of gender informed policy must be prioritised. Recommendations The Australian Women s Health Network recommends the Commonwealth Government: 1. increases funding for health promotion, prevention and early intervention as an effective, long term strategy to: improve Australian community health outcomes; reduce demands on expensive emergency and tertiary services; and achieve a sustainable healthcare system. 2. explores alternative revenue raising options, such as through the reallocation, increase or introduction of taxation on corporations benefiting from the sale of products which impact negatively on the health of Australians. For example, products whose manufacture result in high levels of carbon emission and those which contain very high levels of sugar, such as soft drinks. 3. prioritises the development and implementation of gender informed workforce and health policy that are sensitive to the needs of women and support the equitable recruitment, retention and promotion of women, particularly to executive positions, in the health workforce. 6 P age

7 References 1. ABS (2012) Australian Health Survey: Health service usage and health related actions 2. AIHW (2012), Australia s health Searles et al, (2007), Reference pricing, generic drugs and proposed changes to the Pharmaceutical Benefits Scheme 4. The Commonwealth Fund Fairchild Causes of Death Australia 2011 Australian Bureau Statistics. 14 March Building a 21 st Century Primary Health Care. Department of Health and Ageing p ABS (2011) Community Service Workers Australian Social Trends, Sep Australian Federation of Medical Women (2004) Moving on from one size fits all: towards gender mainstreaming in medicine. Discussion paper, AFMW, East Melbourne. 10. Department of Health and Ageing (1989) National Women s Health Policy Commonwealth of Australia, Canberra. 11. Leach M, Segal L, May E. (2010) Lost opportunities with Australia s health workforce? MJA 2010; 193, pp NATSEM (2012) The cost of inaction on the social determinants of health. Report no. 2/2012.National Centre for Social and Economic Modelling for Catholic Health Australia, University of Canberra. 13. Productivity Commission (2005) Australia s Health Workforce, Research Report, Canberra. 7 P age

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