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1 International Health approaches Expenditure: to funding Its Management health care and Sources Occasional Papers: Health Financing Series Volume 3 Prepared by Bill Ross, Adrienne Hallam, Jamie Snasdell-Taylor, Yael Cass and Louise Clarke; Commonwealth Department of Health and Aged Care Tony Hynes and John Goss; Australian Institute of Health and Welfare

2 Commonwealth of Australia 1999 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without permission from AusInfo. Requests and enquiries concerning reproduction rights should be directed to the Manager, Legislative Services, AusInfo, GPO Box 1920, Canberra ACT Health Financing Series Volume three ISBN Publication approval number: 2649 Papers published as part of the Occasional Paper Series are not meant to be prescriptive and do not represent any official Department of Health and Aged Care position. They are intended to further stimulate discussion on a range of critical issues, and cover essential points of the debate. The views expressed in these papers are not the views of the Commonwealth Government. This paper is also available on the Department's web site: For further information about this paper contact: Occasional Papers Department of Health and Aged Care Portfolio Strategies Division MDP 85 GPO Box 9848 Canberra ACT 2601 Text layout and design by Sue Hunter

3 Foreword Much of the public focus on Australia s health care system is around issues of how to best provide high quality, accessible care at a reasonable cost. That is a discussion well worth having. Yet frequently that discussion is polarised around arguments about whether the health system as a whole, or at least important components of it, are in crisis or unsustainable. Concerns about public hospital waiting lists and the affordability of private health insurance are two examples of this manifestation. Against that, there are also many good news stories about health: exciting new medical and pharmaceutical breakthroughs, or gains in public health through successful immunisation campaigns being examples. The fascination about health issues and the debate about priorities and approaches is understandable and necessary. At one level, birth, sickness and eventual death are aspects of life that confront all of us. We want the best for our families and more generally for society as a whole. At another level, almost one in every twelve dollars spent in Australia is directed at health care. The point is that we all have a keen interest in good health and in finding ways of better achieving it. In Australia, we have a health system that serves us well, and compares well, on many key indicators, to overseas systems. While there is room for improvement, the complexity of the system makes it difficult to agree on where improvements are needed, what trade offs we are prepared to make in order to gain these improvements, and what changes will deliver the results we seek. Hence the presence of as many, if not more, solutions in the debate as there are stakeholders. This series of papers coming out of the Department s Health Financing Project is intended to contribute to the debate by providing data and analysis that is not generally easily accessible. The papers are by no means the last word on these subjects; they do not seek to cover all perspectives, for that would be too big a task. This third volume of the series examines health expenditure in Australia, the drivers of growth and the tools available to manage health expenditure. A description of the changes in the sources of funding over recent decades is also provided. Other papers in the series consider a range of health financing and related issues. We hope that you will find these papers a useful contribution to the debate. David Borthwick Deputy Secretary December 1999

4 Contents 1. Introduction Growth in health expenditure the Australian and overseas experience...5 Growth in Australia... 5 Growth overseas Why manage health expenditure? The relationship between health expenditure and health outcomes Variations in practice Managing health expenditure: identifying drivers of growth Demand-side drivers Supply-side drivers Cost containment strategies Demand-side cost containment measures Supply-side cost containment measures Restricting supply Influencing supplier behaviour Health expenditure growth and management in Australia Australian health financing arrangements and environment Broad approaches to expenditure management in Australia Growth in specific areas of expenditure... 43

5 Medical services Pharmaceuticals Hospitals (public and private) Conclusion Acronyms Bibliography A History of Funding Sources: Australia to Overview Changes in sources of funding for total recurrent expenditure.. 81 The distribution of expenditure Changes in sources of funding to to to to to Changes in importance and sources of funding for specific services Changes in importance and sources of funding for hospitals Changes in importance and sources of funding for medical services Changes in importance and sources of funding for pharmaceuticals Changes in importance and sources of funding for nursing homes Changes in importance and sources of funding for dental services

6 Appendix 1: Tables Appendix 2: Methodology for decomposing source of fund changes Appendix 3: Health insurance arrangements 1969 to to July 1975 to 30 September October 1976 to 31 October November 1978 to 31 August September 1979 to 31 August September 1981 to 31 January February 1984 onwards Medicare Acronyms List of Data Sources

7

8 Executive Summary Health expenditure is a topic that generates public and political concern both in Australia and overseas. Public debate reflects concerns that we both spend too much and too little. Those who are concerned that we spend too much generally point to the growth in health expenditure and suggest that the demands of the future are likely to be so great that we will be unable to afford our health unless radical changes are made. Those who argue that we spend too little point to waiting times for elective surgery in the public hospital system and press reports of patients being discharged from hospital before they are ready to go home. Just as the Australian public debate about health expenditure reflects the debate in overseas countries, so too does our health expenditure. Australia spends a little more than eight per cent of gross domestic product (GDP) on health, which is about average for Organization for Economic Cooperation and Development (OECD) countries. Like that of comparable OECD countries, Australia s health expenditure has been growing in real per capita terms at an average annual rate of around 2.6 per cent since This growth is associated with some undeniable benefits. Hip replacements, cataract surgery and heart bypass operations are now common place and the associated improvements in quality of life are taken for granted. It is difficult, however, to draw a direct relationship between health expenditure and the health benefits derived from that expenditure. While some of the growth in health expenditure over the past 30 to 40 years has delivered tangible benefits, some of the additional expenditure has not. Without active management, there is no guarantee that health expenditure will deliver health benefits. Growth in health expenditure is driven by a wide range of factors. This growth is most strongly associated with increasing national income: as incomes increase, so too does health expenditure. Other demand-side factors are growth in the population and demographic changes in the population, such as ageing and increasing consumer expectations. On the supply side, new technologies (especially new pharmaceuticals) and increased supply are important factors, as is the capacity of suppliers to generate demand for their services. In common with other countries, some areas of the Australian health sector have grown much faster than others. Since the beginning of Medicare in , the greatest contribution to growth has come from medical services, hospitals and pharmaceuticals and government efforts to manage expenditure have been focused in these areas. Predictions concerning future growth in Australian health expenditure vary considerably. There is general agreement, however, that health expenditure will continue to grow and probably grow as a proportion of GDP. Despite continuing publicity about the impact of ageing on future health expenditure, the impact of ageing will be small and outweighed by growth in the utilisation of health services. 1

9 Occasional Papers: Health Financing Series Some of this future growth in health expenditure can be expected to deliver real benefits in health outcomes and quality of life. No society would choose to forgo these benefits. Future management of health expenditure will, therefore, need to distinguish between growth in expenditure that is beneficial and growth in expenditure that is not. The Australian health care system provides the vast majority of Australians with quality care at a cost comparable with other countries. This has been achieved through the use of a range of financing measures which, while largely consistent with overseas experience, also reflects Australia s institutional and cultural circumstances. However, there is little room for complacency. Managing health expenditure in Australia will need to continue to evolve through ongoing improvements in health care, as well as the tools to manage health expenditure.

10 Managing Health Expenditure 1. Introduction Health expenditure is often a source of public concern and debate in Australia. On one hand, debate characterises health expenditure as out of control and unsustainable, while on the other there are claims that waiting lists are too long and not enough money is available to meet health care needs. Health expenditure is a very large part of Australia s economy, accounting for around 8.4 per cent of GDP or roughly one out of every twelve dollars spent in Australia. At the same time, health, and therefore expenditure on health, is also a central concern to all, as no one wants illness to go untreated. The health system is financed from a combination of public and private funds. Public funds account for approximately 69 per cent of total expenditure and are sourced from the Commonwealth, State, and local governments (AIHW, 1999). Health expenditure accounts for approximately 16 per cent of Commonwealth outlays (Commonwealth of Australia, 1998, p124), and approximately per cent of State government expenditures. 1 Private funds are sourced from private health insurance schemes, other insurance schemes (for example, workers compensation) and out-of-pocket payments by private citizens. As taxpayers and health care consumers, health expenditure is a legitimate area of concern. Fuelling this concern is the level of growth in health expenditure. Over the past 30 years the health sector of the Australian economy has grown faster than the economy as a whole. On current trends in Australia and internationally, this is expected to continue. These concerns about the absolute level, source and growth in health expenditures need to be viewed in some context. Firstly, the absolute level of health expenditure in Australia is consistent with that in comparable nations. Australia spends more than the United Kingdom, but less than Canada and significantly less than the United States, for apparently comparable levels of health services and outcomes. The public sector contribution to health expenditure is lower in Australia than in many comparable countries. 1 Based on and State Budget figures. 3

11 Occasional Papers: Health Financing Series Secondly, the level of public funding for health reflects a community decision on two grounds. Society has decided that a basic amount of health goods and services ought to be made available to every eligible resident and that government intervention is appropriate in the health sector to correct market failure. There is, of course, room for debate about whether these are the right decisions implemented in the right ways. This debate is the subject of Volume 4 of this series. Thirdly, while some growth in health expenditure is bad, other growth is good. In the late 1990s health care is being provided to more people and for more conditions than in the 1960s. In this light, it is no surprise that health expenditure has grown over the past 30 years. This does not say, however, that all of this money is well spent. It must still be asked whether the money spent on health: could be better spent elsewhere in the economy (and vice versa); could be better spent elsewhere in health; and is being used efficiently. Managing health expenditures is about attempting to ensure that the appropriate level of resources is devoted to health and that those resources devoted to health are used optimally. As noted in The Objectives of Health Financing, in Volume 1 of this series, there is no right level of health expenditure this is a community or political decision. Nevertheless, by concentrating on the effective use of health resources, we can go some way to moving towards the right level. A more efficient health sector would free up resources for other desirable activities (both public and private) and an efficient health sector may be in a better position to argue for more resources when a need is identified. This paper begins by examining overall growth in health expenditure in Australia and comparing it with the growth experienced overseas. Section 3 discusses the reasons to manage health expenditure and canvases some evidence of less-than-optimal use of resources both in Australia and overseas. A discussion of the drivers of growth in health expenditure follows in section 4 and the techniques used to manage health expenditure here and overseas in section 5. Section 6 examines areas of growth in the Australian health system and the approaches that have been used to moderate that growth. 4

12 Managing Health Expenditure 2. Growth in health expenditure the Australian and overseas experience An important element driving the debate about health expenditures, both in Australia and overseas, has been the growth in health spending. It is the rate of growth, rather than the absolute size of health outlays, that has given rise to concern. This section briefly reviews the Australian experience of growth in health expenditure and compares it with overseas experience. Growth in Australia Health expenditure in Australia has consistently grown faster than the economy as a whole. Figure 1 shows the growth in nominal health expenditure and nominal GDP since Figure 1: Growth in Australian health expenditure* and GDP nominal prices, to ,000 Index (1960=100) 5,000 4,000 3,000 2,000 1,000 Health Expenditure GDP * Direct expenditure, not adjusted for taxation. Sources: OECD (1998); AIHW (1998b, 1999) Health expenditure has grown by a factor of almost 60 since 1960, while GDP has grown by little more than a factor of 30. The average rate of growth in real health expenditures since the advent of Medicare in has been 4.3 per cent per annum. This was a higher rate of growth than that for the economy as a whole, which was around 3.6 per cent over the same period. 5

13 Occasional Papers: Health Financing Series Adjusted for inflation and population growth, the picture is less dramatic (see figure 2). 2 Figure 2: Growth in Australian health expenditure real prices, to Index (1960=100) Real growth Real per capita growth Sources: OECD (1998), AIHW (1998b, 1999) In real terms, growth in health expenditure has more than quadrupled over the past 37 years, increasing at an average rate of 4.2 per cent per annum. When price inflation and population increases are both filtered out by measuring the growth in real health expenditure per capita, the factor by which health expenditures have increased shrinks to just under 2.5 per cent per annum. While health expenditure growth in real per capita terms is clearly less alarming than growth in nominal health expenditure, it still indicates that health expenditures are rising significantly over time. Growth in real health expenditure per capita averaged 2.59 per cent per annum over the period to , with growth slightly greater at an average of 3.41 per cent per annum in the six years from During these periods, real per capita GDP grew at an annual average rate of 2.23 per cent and 3.82 per cent respectively. The size of the Australian health sector grew from 4.9 per cent of GDP in the 1960s to 8.4 per cent of GDP in The introduction of the Medibank scheme was accompanied by a pronounced increase in direct expenditure and there has been steady growth since the introduction of Medicare. Expenditure was relatively stable in the period between the two schemes, when four different arrangements were introduced in the space of a little over seven years. Between the first full year of Medicare in and , health expenditure per capita has risen from $1,448 to $2,118 (in dollars). This equates to an average yearly growth rate in health expenditure per capita of 2.97 per cent. Since , health expenditure in Australia has risen from 7.6 per cent to 8.4 per cent of 2 Throughout this paper, a price deflator based on total health expenditure is used to convert from nominal to real prices. This implicit price deflator has been derived from real and nominal figures for total health expenditure sourced from OECD (1998) health data for to , AIHW (1998b) data for to and AIHW (1999) data for to

14 Managing Health Expenditure GDP. Perhaps the most notable statistic though is the absolute size of the health sector, which in was measured by the Australian Institute of Health and Welfare (AIHW) as approximately $47.3 billion (OECD, 1998; AIHW, 1998b; AIHW, 1999). Areas within the Australian health system identified as having particularly strong growth include the medical services and pharmaceutical sectors. Between and , expenditures on medical services and pharmaceuticals rose as a proportion of recurrent (non-capital) expenditure from 19.0 per cent to 19.7 per cent and from 9.9 per cent to 12.2 per cent respectively (OECD, 1998; AIHW, 1999). As a proportion of the economy, however, health expenditure has remained relatively stable in recent years, growing from 8.15 per cent in to 8.36 per cent in the six years to The growth in real per capita health expenditure has been constant over this period and the growth in health expenditure as a proportion of GDP has been a result of fluctuations in real per capita GDP (see figure 3). Figure 3: Growth in real per capita health expenditure, real per capita GDP and health expenditure as a proportion of GDP, to Index ( =100) Percentage G ro w th in rea l p er ca p ita h ea lth ex p en d itu re (left a x is) G ro w th in rea l p er ca p ita G D P (left a x is) H e a l t h e x p e n d i t u r e a s a p e r c e n t a g e o f G D P ( r i g h t a x i s ) Source: AIHW (1999), ABS Cat In the same period, expenditure associated with the Medicare Benefits Scheme (MBS) and the Pharmaceutical Benefits Scheme (PBS) slowed. From to , real per capita expenditures associated with the MBS and PBS grew at an annual average of 2.60 per cent and per cent respectively, whereas from to this had slowed to 1.10 per cent and 7.77 per cent respectively (Commonwealth Department of Health and Aged Care, 1999). 3 The share of publicly financed health expenditures has risen from about 52 per cent to more than 69 per cent in the past 37 years (OECD, 1998; AIHW, 1999b); however, this growth in the public share is overstated because tax expenditures, which were a particularly important source of funds in the late 1960s and early 1970s, were not 3 The PBS growth figures include patient copayments. 7

15 Occasional Papers: Health Financing Series included in the figures. Of a group of 10 OECD countries, Australia ranks equal eighth, with Canada, in terms of the public share of total health expenditures (OECD, 1998). 4 Growth overseas While direct comparisons are not easy, the data available indicate that Australia s growth in health expenditure is consistent with the experience of other nations. 5 Figure 4 shows total health expenditures as a percentage of GDP since 1960 for Australia, Canada, Sweden, the United Kingdom and the United States. Using total health expenditure as a percentage of GDP to compare the experiences of different countries shows the amount of resources a country diverts to health relative to the rest of its economy. There is nothing to say that a particular level of health expenditure as a proportion of GDP is either good or right. Nevertheless, this measure does provide a starting point for understanding the similarities and differences in health financing between countries. Figure 4: Total health expenditure as a percentage of GDP, 1960 to 1996 % GDP Australia Canada Sweden UK USA Source: OECD (1998) 4 The 10 countries were the United Kingdom and Sweden (83 85%), Sweden, Germany, Japan and New Zealand (77%), France and the Netherlands (72 74%), Australia and Canada (69%) and the United States (47%). 5 There are four broad reasons why international comparisons of health expenditures are difficult. Firstly, the definition of the boundary of the health sector is different for different countries (for example, the Australian data exclude amounts spent on institutions other than acute care hospitals, psychiatric hospitals and nursing homes as these are classified as welfare institutions). Secondly, institutions such as acute care hospitals may actually perform different tasks in different nations. Thirdly, reported levels of health expenditure in many countries actually exclude the tax concessions that arise when governments allow tax deductions for some private expenditure on health goods and services. Fourthly, comparisons do not generally take into account factors such as population age profiles, rurality and proportion of indigenous peoples which may affect health expenditure. This is true of figure 4. 8

16 Managing Health Expenditure Figure 4 shows that the total expenditure on health in each country has increased in real terms since the 1960s. On average, the proportion of GDP devoted to the health sector has doubled since that time. All countries represented in figure 4 experienced a levelling off of health expenditure as a share of GDP after Total health expenditure as a percentage of GDP is just as sensitive to changes in the rate of economic growth as it is to changes in the rate of growth of health expenditures. There appear to be three periods of sharp growth common to all of the countries examined. These occur in the mid 1970s, the early 1980s, and the early 1990s. These common spikes occur at times when most countries within the OECD experienced a slowdown in economic growth. This occurs because health expenditure grows at a reasonably constant rate that does not slow when growth in the general economy slows. Nevertheless, figure 4 highlights that Australia s total health expenditure has withstood the periods of sharp growth better than several comparable economies. Figure 5 shows total per capita health expenditures for the same five countries, expressed as purchasing power parities (PPP). For the countries examined, with the exception of the United States, the growth rate of per capita health expenditure has been constant since the early 1970s. Figure 5: Per capita health expenditure (PPP), 1960 to 1997 $PPP Australia Canada Sweden United Kingdom United States Source: OECD (1998) 9

17 Occasional Papers: Health Financing Series 10

18 Managing Health Expenditure 3. Why manage health expenditure? Much of the public debate about health expenditure focuses on the growth trends in that expenditure and alleges that continuation of the current arrangements will soon see health expenditure consume a significant and ultimately unsustainable proportion of government expenditure and the economy as a whole. Real per capita health expenditure grows at a roughly constant rate and health expenditure as a percentage of GDP is also growing, albeit more slowly, and can be expected to continue to grow. It is often suggested that the extent to which this growth can be moderated depends to a large extent on what we are prepared to give up many commentators suggest that increased rationing and user charges are inevitable (Ferriman, 1999). The extent to which these predictions are realised depends on our capacity to use existing and future health resources more efficiently than at present. If health expenditure grows without returning offset benefits to the community, then at some point spending on health services will be to the exclusion of goods and services currently regarded as important. Exactly when this becomes unacceptable is a matter of personal opinion, but few Australian commentators would regard the United States level of health expenditure, at 14 per cent of GDP, as satisfactory for Australia. Health expenditure delivers two types of benefits to individuals and the community: quality of life benefits, including increased life expectancy, increased mobility and independence and reduced levels of pain and discomfort; and economic benefits, including reduced levels of dependency on support services (such as home help and residential care) and improved capacity to participate in the workforce. For the most part, quality of life benefits are associated with economic benefits, although in some circumstances a quality of life benefit, such as a reduction in mild chronic pain, may have little or no discernible associated economic benefit. In general, however, economic benefits are associated with improved quality of life. For example, a health system that could prevent three working days a year per capita being taken off due to ill-health would deliver a 1.2 per cent increase in productivity, equivalent to the annual gains most countries regularly aspire to (but only tend to achieve in good years) (Commonwealth Department of Health and Aged Care, 1999a). To understand whether future levels of health expenditure are likely to be unsustainable we need to consider: the level of economic benefit associated with health benefits; and the level of health benefits derived from health expenditure. Both are difficult to quantify. It is these factors, however, that will in part determine the rate at which increased real per capita health expenditure will translate into increased health expenditure as a proportion of GDP. Other factors, such as the age at which people leave the workforce, will also affect trends in health expenditure as a proportion of GDP. 11

19 Occasional Papers: Health Financing Series Estimates of future health expenditure vary according to the assumptions on which they are based. For example, in Australia: Cooper and Hagan (1999) conclude that the annual percentage increase in publicly funded health expenditure due to population growth and ageing will be 1.2 per cent over the period (0.5% per annum for ageing alone). They conclude that this rate of increase is less than historical average annual growth rates in GDP and hence that increasing (government) costs due to population growth and ageing alone should not increase as a proportion of GDP over the longer term; Bacon (1999) reports that the Retirement Income Modelling Unit estimated that health expenditure could reach 17 per cent of GDP by 2041, assuming a 1.25 per cent growth in GDP per capita and a tow per cent growth in per capita health expenditure in all age groups; Badham (1998) modelled changes in health expenditure, including adjustments for population growth, ageing, costs related to proximity to death and increased utilisation (based on historical trends). The results indicated that, after allowing for annual productivity increases of 1.4 per cent per person aged years, total health expenditure would be 13 per cent of GDP in 2021; and Clare and Tulpule (1994) estimated that health expenditure would reach 11.1 per cent of GDP by They assumed that real per capita expenditure on health would be in line with rising standards of living (reflecting growth in labour productivity) around one per cent per year within each age group equating to an average annual increase in total health expenditure of around 2.4 per cent. Although estimations of future health expenditure vary, there is general agreement that health expenditures will continue to grow, and probably grow as a percentage of GDP. The consensus about the quantum of this growth seems to be that health expenditure will be per cent of GDP by These predictions, particularly those nearing 20 per cent of GDP, are alarming. It is unlikely that Australia would be comfortable spending 20 per cent of GDP on health, whether this is publicly or privately funded, and regardless of perceptions of receiving value for money. While estimations of growth for other sectors of the economy are prepared on the assumption that bigger is better, these estimates of the growth in the health sector cause concern. This is because: the health sector is regarded as less efficient than it could be there are significant variations in clinical practice and there is little relationship between health expenditure and health outcomes (discussed below). As a large sector of the economy (health accounts for one in every twelve dollars spent in Australia), significant levels of inefficiency in the health sector have a real impact on the performance of the economy overall. Under-performance in the health sector means that resources that could be used elsewhere (whether in health or other parts of the economy) are being wasted; and government outlays account for a significant proportion of health expenditure (a majority in most OECD countries and 69 per cent in Australia). Neither governments nor taxpayers appreciate areas of government expenditure which grow without demonstrated benefit and outside of government control. The same argument extends to other large areas of government expenditure, including education and social security. 12

20 Managing Health Expenditure These factors prompt government attempts to manage health expenditures. In addition, government intervenes to: address market failure and in particular to ensure that the health system provides high quality care. In this context, over-utilisation of health services is as much an issue of concern as under-use and misuse. Since consumers are not well placed to identify their health care needs and usually rely on advisers who are also their service providers, government involvement in ensuring overall safety and quality of health care services is warranted to protect consumers; and manage consumer expectations of the availability and appropriateness of care. In part, this is because the perception of better access to services in the private sector has the potential to result in community pressure to expand essential services provided through the publicly funded health system. While dedicated expenditure on the health system is but one area in the broad range of social, economic and environmental factors that affect overall health outcomes, the following briefly reviews the evidence that there is no direct relationship between health expenditure and health outcomes. If there were a clear and direct relationship, the benefits of additional health expenditure would be relatively easy to identify. Without such a relationship, it can be argued that there is considerable inefficiency within the health sector and that a more efficient use of resources is possible. The relationship between health expenditure and health outcomes The five countries examined in section 2 exhibit substantial variation in health expenditure as a percentage of GDP despite being at similar stages of socioeconomic development. It is worth examining whether those countries that spend relatively more on health get better health outcomes. The presence of a direct relationship between additional expenditure and improved outcomes would tend to suggest that countries diverting proportionately more resources towards the health sector have a relatively strong preference for health per se. However, the absence of such a relationship would be cause to examine the cost-effectiveness of health systems on a case by case basis in an effort to identify the causes of such wide variation in health expenditure levels. Evans (1996) notes that there is overwhelming evidence that health systems can be operated on vastly different budgets and that, at the micro-level, practice patterns can vary enormously without any known relationship to medical benefit. The apparent lack of a relationship between health expenditure and health outcomes is shown in table 1 for five OECD countries. 13

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