Out of pocket costs in Australian health care Supplementary submission

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1 Out of pocket costs in Australian health care Supplementary submission The AMA welcomes the opportunity provided by the Senate Community Affairs References Committee to make a supplementary submission on the announcements on health care financing made by the Government in the Budget. The AMA remains committed to the principle of co-payments but does not support the Government s model of co-payments as proposed in the Budget. It is poorly designed, and is bad health policy because of potential perverse outcomes which create even greater demand for more expensive health services. Health Budget facts The Government is reducing its financial assistance to patients for their health care costs in several ways, each with a cumulative effect on the other: $5 cut to Medicare rebates for general practitioner (GP) attendances and all pathology and diagnostic imaging services, and removal of bulk billing incentives for pathology and diagnostic imaging services for all patients. The cost to patients is $3.5 billion in the first three years of implementation. No indexation of Medicare rebates for all medical services. The cost to patients is $1.8 billion over the next four years including the $160 million already saved by Government in by not indexing Medicare fees on 1 November Simplifying the Medicare safety. The cost to patients is $268 million over the first four years of implementation. Increasing PBS co-payments and the safety net thresholds. The cost to patients is $1.3 billion in the first four years of implementation. Through these structural changes to Medicare and the Pharmaceutical Benefits Scheme, the Government is shifting $8.4 billion of health care costs onto patients over the next four years. Assuming that the $5 rebate cut is offset by the $7 co-payment, the $2 difference imposes a further cost on patients of around $1.4 billion 1. 1 As the AMA does not have any information about the Government s modelling, this is a simple calculation.

2 These costs to patients come with a serious and immediate funding reduction of $1.8 billion for public hospitals and the loss of the $16.4 billion funding guarantee in the National Health Reform Agreement. Public hospitals are the safety net for people who cannot afford private health care. Yet the future of Commonwealth funding for public hospital services is uncertain. The AMA contends that these Budget measures are driven by ideology. They make no attempt to refine and shape the Australian health care system to position it to deal with future challenges. Structural changes of this magnitude, without any long term forecasting and analysis of their impact, subject the health of Australians and the Australian health care system to enormous risk. Health spending facts The Government is justifying the health budget measures on the basis that Australia s health spending is unsustainable. It is not. Health is 16.13% of the total Commonwealth Budget, down from 18.09% in Health was 8.9% of Australia s GDP in 2010, stable when compared with 8.2% in 2001, and lower than the OECD average of 9.3%. The Government fails to acknowledge that Australia s nominal GDP continues to grow at rates that are above OECD averages 2. Australia can afford the health system it currently has. Utilisation of general practitioner services is not out of control. Since : The population has grown on average by 1.51%. Medicare funded GP services has grown on average by 2.47%. GP services per capita have grown on average by 0.94%. 3 This is despite an increase in the practicing GP workforce, to the tune of 3.5%, which has occurred as a direct result of Government initiatives. Impact of the Government s co-payment model Every day, medical practices ascribe Medicare Benefits Schedule (MBS) item numbers to, and electronically lodge claims on behalf of their patients for, tens of thousands of medical services. This allows patients to access their Medicare rebates quickly and with little effort. It also allows the Department of Human Services to process in excess of 310 million patient rebates each year quickly and with very little administrative cost to the taxpayer. For efficiency, many medical practices gear their business models to this arrangement. The Government is seeking to shift the community s expectation that health care should be free at the point of service by applying a pricing signal. It will achieve this by reducing the 2 OECD Economic Outlook, Volume 2014, Issue 1, Annex Table 2, Nominal GDP: Percentage change from previous year, page 262 (last updated: 28-April-2014) 3 Department of Health. Annual Medicare Statistics Financial Year to Group Statistics Report. Table 1.1. Non-referred attendances GP/VR GP; Department of Health. GP Workforce Statistics /85 to 2012/13 ; Australian Bureau of Statistics. Estimated Resident Population ABS catalogue Australian Demographic statistics, December 2009 released 26/4/

3 patient rebate and bulk billing incentives by an amount that cannot realistically be absorbed by medical practices. From the consumer perspective, the Government s cuts will manifest as an increase in doctors fees. Rebate cuts The $5 rebate reductions to GP and pathology services are significant. It is a 13% cut to a standard GP consultation. It is a cut of between 28% and 70% for the 114 pathology tests with MBS fees under $25. The AMA cannot accept the $5 cut to patient rebates because of the significant impact on medical practices. Medicare funding of pathology and diagnostic imaging services will be further reduced through the loss of the bulk billing incentives that currently apply to all patients: >$3 per service for pathology services; equal to 10% of the MBS fee for diagnostic imaging services. Co-payments and low gap incentives for concession card holders and children under 16 For concession card holders and children under 16 years of age, low gap incentives and higher rebates will be contingent on the medical practitioner charging these patients exactly $7. Medical practitioners will be forced to charge the co-payment, or otherwise absorb the rebate reductions and the loss of the bulk billing incentives for these patients. For many practices the latter will not be an option. Direct financial impact on patients As most medical services do not occur in isolation of each other, the Government s measures will have an immediate, cumulative impact on patients. A young woman with a breast lump illustrates the different financial impacts for general patients and those with concession cards and children under 16. For the various medical examinations and diagnostic tests to arrive at a conclusive diagnosis, a concession card holder will have to outlay at least $49 and a general patient will incur at least the amount of the Medicare rebate reductions totaling $ These costs must all be incurred within a week, rather than spread out over a longer period of time. Similarly, patients who are commencing warfarin treatment require initial dose adjustment and ongoing monitoring. There is usually a large number of visits, every few days at first, for international normalised ratio testing to determine whether the blood is too thin or thin enough. Concession card holders will incur their 10 co-payments quickly, along with increased PBS co-payments. Families will experience similar concentration of health care costs which will affect household budgets because the co-payments apply to individuals and are not counted on a family basis. Accumulated co-payments will not count towards the new Medicare Safety Net. The revised benefits will no longer cover out of pocket costs in the same way that they are currently covered. While the thresholds will be lower, they will be harder to reach. 3

4 A patient who is sick and needs tests, repeat GP visits, and medication during an episode of illness would face a significant accumulated financial burden. The consequences of delayed diagnosis and not getting therapy right can be severe. The issue then is whether patients will not seek or delay medical care. The AMA does not believe there will be sufficient safety nets in place to ensure that certain patient groups are not deterred from seeking medical assistance because of out of pocket costs. Getting this safety net right is critical to avoiding the additional downstream costs to the health system of delayed diagnosis and treatment. Impact on patient care International evidence shows that poorly designed systems of co-payments raise barriers to accessing care and impact most on people of low socio economic status. These people normally suffer from more health problems than the general population and need to utilise more health services. Putting additional cost barriers in front of these patients through the application of co-payments at multiple points in the health system will inevitably discourage them from accessing relatively low cost health care. Indigenous Australians defer or avoid care due to costs: one-third delay or do not fill prescriptions and one in eight delayed or did not got to a GP 4. Indigenous Australians are three times more likely to die from a potentially avoidable cause 5. The Government s co-payment will hamper Australia s collective efforts to close the gap. The COAG Reform Council, reports that 5.8% of Australians have delayed or did not see a GP due to cost, and that 8.5% of people given a prescription by their GP delayed or did not fill it due to cost. These numbers increase to 12.4% for people in the most disadvantaged areas. The Commonwealth Fund Report Mirror, Mirror on the Wall, How the Performance of the U.S. Health Care System Compares Internationally (June 2014), ranked Australia 9 th out of 11 countries in terms of cost-related access problems for healthcare, with only the USA and France rated worse. It reports that in 2013, 16% of Australians did not: fill a prescription; skipped recommended medical tests, treatment, or follow-up; or had a medical problem but did not visit a doctor or clinic in the past year because of cost. The impact of the budget measures on patient care cannot be ignored - workable alternatives must be found. Practicalities of collecting the Government s co-payment and out of pocket costs There are practical problems with the proposed co-payment, starting with the need to collect a payment in situations and for patients where this has not previously been required, such as in nursing homes and Aboriginal Medical Services, both of whom are highly vulnerable groups of patients. For pathology services, in around 50 per cent of cases pathologists never see or have contact with the patient. The specimen may be sent to the laboratory by the referring doctor, making 4 COAG Reform Council Healthcare in Australia : Five years of performance. Page Ibid page 27 4

5 the co-payment logistically difficult (if not impossible in some circumstances) and costly to collect. For diagnostic imaging services, general patients that have previously received higher rebates for bulk billed services will be required to pay the full fee upfront as currently occurs with patient billed services. Not every patient will have more than $900 to pay up front for their PET scan following treatment for cancer. The proposed co-payment model is at odds with the Government s long stated commitment to reducing the red tape burden on business. Practices will need to be able to determine patient eligibility for co-payment thresholds, put in place additional infrastructure and incur all the usual costs associated with the collection of cash and electronic payments. Complexity A crucial test for any healthcare arrangement is simplicity, ease of understanding for patients and healthcare providers, and minimal overhead costs to implement and operate. The measures are extremely complex. Not surprisingly, public commentary on the proposed measures has been confused and factually incorrect, including comments by the Prime Minister, the Treasurer, individual Members of Parliament and media commentators. The focus has been on the $7 co-payment and the public has been (incorrectly) told that people with chronic disease and or people on low incomes will not have to pay them. The $5 rebate reductions and the loss of bulk billing incentives for pathology and diagnostic imaging and the significant impact on out of pockets costs are not well understood by the general community. This confusion has extended to patients, with the AMA receiving reports from practices of people not attending for GP consultations because they thought the co-payments had already begun. Some people who currently pay out of pocket costs believe they will only have to pay $7 in the future. Non-indexation of Medicare rebates Indexation of rebates for other medical services specialist, consultant physician and psychiatry consultations, and operations and anaesthesia last occurred on 1 November The Budget measure to pause indexation until July 2016 amounts to a four year freeze of the Medicare rebate the Government will pay towards the cost of specialist medical care. The private health insurers may decide not to carry the Government s savings by indexing their schedules of medical benefits they may decide to freeze indexation for a similar period of time. If that happens, there will be a drop in the current high rate of 89% of privately insured services that have no out of pocket costs. This four year price freeze, and its impact on the cost of private hospital treatment is also not well understood by the general community. Conclusion 5

6 The Government s proposed model of co-payments, coupled with across the board rebate reductions, poor safety nets for the vulnerable and those with chronic disease, and significant reductions to public hospital funding are too harsh, and will have as yet unexplored consequences for the health of the nation and the downstream impacts on health care costs. At this point in time, there is no financial reason to make such dramatic and experimental changes to the structure of health care financing in Australia. The AMA recognises that thought must be given to the long-term sustainability of the Australian healthcare system but we should take the time to properly design that system to avoid unfair and perverse outcomes. 6

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