Article originally printed in www.smh.com.au
The Coalition government has told us we need to have an “everything on the table” debate on how to rein in healthcare expenditure.
Yet signs of a vigorous debate are as hard to find as therapeutic molecules in a homeopathic preparation. In essence, we are being told we must pay more for our health programs while simultaneously denuding them of millions of dollars.
The intellectual property underpinning the government’s plan is focused on the introduction of a co-payment of $6 when visiting a GP and, more recently, the introduction of a fee for visiting a hospital’s emergency department with a “GP problem”.
Virtually all commentators have rejected the co-payment idea as poor policy that would raise very little money. Hospital expenditure dwarfs Medicare spending yet our inadequate primary care infrastructure fuels one of our most telling statistics. About 600,000 admissions to hospital each year (at an average cost of $5000) could be avoided if we had the infrastructure to provide community based interventions in the three weeks prior to a hospitalisation. This would cost only $300 a person treating at a community health level, compared with $5000 for a hospitalisation.
Seeking help at an emergency department (ED) for a problem that could be managed by a GP, we are told costs the system $1billion a year. This is nonsense. Some studies have estimated that in a fully staffed well-established “ED”, the additional real costs involved in seeing such a patient is around $10. Such patients do not clog up EDs or interfere with the treatment of real emergencies. ED physicians are exasperated at the continued focus on this non-problem rather than the real “no room at the inn” problem of our hospitals’ capacities, safety and efficiency.
There are a number of valid reasons for sick people to visit an ED. Often no GP is available and patients may not be confident it is not serious (particularly when children are involved). It is common for such patients, on assessment, to be in need of admission. While it may be preferable in terms of waiting times and continuity of care to have these patients assessed outside of the hospital setting, to suggest charging for this would save billions of dollars is ridiculous.
It’s a bit rich to ask Australians to pay more for more of the same old. We are already contributing $30billion from our pockets to supplement our healthcare (only Americans spend more) and increasingly, those who cannot find the extra cash are suffering inferior health outcomes. This fuels inequity that should be regarded as un-Australian but, in any case, is certainly expensive as we all end up paying much for those with chronic diseases. The debate, were we to engage in one, should be focused on major health system reforms to provide us with better health from changes that are more cost effective and sustainable.
Consider the following annual costs. Nine departments’ of health for 23 million people costs $4billion in duplication and lack of healthcare integration. Avoidable hospital admissions at approximately $5000 a patient per visit, cost us about $30billion. As much as $20billion could be saved by eliminating inappropriate interventions, a challenge my profession is tackling, but too slowly. The $5billion used to subsidise private health insurance should be redirected to our public hospitals. The rebate did not increase the uptake of private health insurance and did not relieve pressure on public hospitals. We could go on to discuss the costs of rural healthcare inadequacy, the savings we are not generating because of the lack of an electronic health record and modern health IT. All these facts should lead to calls for our political leadership to take us on a reform journey – not an easy “you pay more, we’ll pay less” strategy. That’s lazy – not professional governance.
A health reform journey must start with a desired destination. International experience suggests the cultural, societal, professional and fiscal rearrangements needed would see our reform journey take about 10 years. We do have the time needed to avoid fiscal panic. We spend just over 9 per cent of our gross domestic product on health, a middle of the road figure for Organisation for Economic Co-operation and Development countries. The changes we want will keep our expenditure manageable.
At our destination we would find, among many improvements, an Australia that has moved from a sickness, hospital and doctor-centric system to one that provides world’s best practice “integrated primary care”, where teams of professionals help us stay well and minimise our need for hospital admissions. The government would be the single funder for the public health system allowing us to, at last, seamlessly integrate primary, community and hospital care.
We should be demanding reform rather than asking us to pay more money for a system that no longer meets the needs of Australians.
John Dwyer is emeritus professor of medicine at the University of NSW.
