Hal Swerissen
Medicare is much loved and it’s a risky business criticising it, as conservative politicians have learnt to their peril when they have sought to restrict or replace it. The current rush by the Opposition to match government proposals to increase funding for Medicare at the next Federal election demonstrates how electorally sensitive Medicare is. Nevertheless, Medicare is now 50 years old and creaking at the seams. Most obviously and recently, out of pocket costs for patients have increased in the middle of a “cost of living crisis”, but there are other more fundamental issues.
Today’s Medicare has its origins in the Medibank program introduced 50 years ago by the Whitlam Government. At the time about a a quarter of the population were at risk because they had no private health insurance and there was no universal public scheme to cover their costs. Medibank meant that all Australians gained access to affordable general practice, specialist, hospital and pharmaceutical care, regardless of their capacity to pay.
Over the last 50 years, universal medical and pharmaceutical care had a bumpy ride. Medibank was scaled back during the Fraser Government and then renamed and revitalised as Medicare by the Hawke Government as part of the Income and Prices Accord with unions and business. But despite the ups and downs, the Medicare fundamentals have remained reasonably constant.
Public hospital care remains free, rebates are provided to patients for a schedule of medical services provided in the community and medicines on the pharmaceutical benefits scheme are subsidised. Patients with health care cards generally get free GP services and much less frequently specialist services as well. Health care card holders and people with other concessional cards also pay less for medicines. More recently, Medicare has been extended and now provides access to a range of allied health services including physiotherapy, psychology, dietetics and podiatry.
In practice, most people think of Medicare as the system that provides them with rebates for medical and pharmaceutical costs in the community. Medicare has been very good at providing affordable access to health care but more recently out of pocket costs have become a problem. Typically, if you go to the GP and you don’t have a concession card, the average out of pocket cost for a standard consultation is now $40.
Less than half of all patients get all their GP services free through bulk billing. Costs are much higher for specialists and only 30 percent of specialist visits are bulk billed. Costs have consequences and about 10 percent of people are now delaying visits to GPs and specialists because of cost.
Out of pocket costs for GPs are reasonably easy for governments to fix, although its not cheap to do so. Increasing rebates and incentives for bulk billing will lead to more bulk billed free care for patients. This is a strategy government has used repeatedly and successfully in the past to fix bulk billing rates for GPs when they fell, and there are current proposals to do that again to vote on at the next election. On the other hand, keeping specialist out of pocket costs under control has proved harder and there are no realistic proposals on the table.
But this is not the biggest issue for Medicare. More fundamentally, as the population gets older, chronic conditions like diabetes, heart disease, kidney disease and respiratory disease have become much more prominent. Over half of Australians have have a chronic disease and 20% have more than one. More than two thirds of Australians have preventable risk factors for developing a chronic disease associated with their weight, diet and physical activity. The incentives in the Medicare funding model were not designed to deal with the dramatic growth of chronic disease.
Medicare provides fee for service rebates to individual health professionals when they provide a service to someone who is ill or injured. This fee-for-service model, while efficient for acute care, inadvertently encourages a reactive approach, neglecting prevention and the long-term management of chronic conditions. Attempts have been made to introduce fee for service GP management plans for chronic disease and mental health but they have not worked. The current Medicare payment model provides incentives for individual services when people are sick or injured, not for keeping people well through integrated team care and prevention. We know this is not a good approach for preventing and managing chronic disease.
Take diabetes as an example. There are around 2 million people with type 2 diabetes and a further two million are estimated to be at risk. Most of these people are overweight or obese. Many have a diet high in sugar, fat, and processed food. Most don’t get enough exercise. These people are on the path to cardiovascular disease, peripheral neuropathy, nephropathy and retinopathy.
Pre-diabetes can be reversed and type 2 diabetes can be effectively managed and even put into remission with changes to diet and physical activity. However, that means a sustained and long term program of diabetes education and behaviour change and follow up. These programs reduce the risk of developing type 2 diabetes by 50-60% and significantly reduce the risk of developing complications.
A more effective Medicare model, let’s call it Medicare Plus, would fund coordinated teams of health professionals, including GPs, nurses and allied health staff to keep the people who use a practice healthy over the long term. These health centres would have ongoing relationships with the people who use them. They would encourage people to have individual health plans focused on keeping them healthy. They would monitor and follow up these plans regularly and provide face to face and online programs to help people manage their own health.
A new Medicare Plus payment model is needed – one that blends payments for consultations when people are sick with payments for keeping people healthy. There are range of ways that could be done, but the important point would be a much greater focus on keeping people healthy by helping them to manage their health more effectively.
Locally, the Springs Medical Practice now runs a gym and a number of programs to encourage people to manage their health more effectively. This is an interesting example of what could be done much more systematically if a Medicare Plus program were introduced nationally.
Dr Hal Swerissen is emeritus professor of public health at La Trobe University. He has a distinguished academic career conducting research and providing advice on health policy and services to government. Dr Swerissen will address the topic ‘”as Medicare reached its used by date?” at the first in a series of Daylesford Conversations starting next Thursday, March 27, at 6.30 pm in the Community Bank meeting rooms 113 Main Rd Hepburn Springs. This is a free event. To assist with seating and catering please book through TryBooking.
