Copayment debate needs leadership

STRONG, “thoughtful” leadership from stakeholders such as GPs and specialists can ensure the $7 Medicare copayment for GP visits is not a fait accompli and does not make it through the Senate, say health policy experts in the wake of the federal Budget.

Professor Geoffrey Dobb, AMA vice-president, said copayments would “change the culture of Australian health care to a huge degree”.

“It is the end of universal health care when even the poorest people and children are liable for up to 10 copayments a year”, Professor Dobb told MJA InSight.

He said it was the AMA’s job to help minimise the adverse impacts and unintended consequences of the federal Budget’s health measures, “particularly in terms of the impact on services for poorer people and children”.

The AMA would work with the federal government to look at the model of general practice in Australia and how it could be improved, he said.

Professor Stephen Duckett, professor of health policy at La Trobe University and director of the health program at the Grattan Institute, told MJA InSight the copayment on visits to the GP was simply “bad policy”.

“It’s not at all clear that [the copayment] will go through the Senate”, Professor Duckett said. “There is already a Senate committee looking at out-of-pocket expenses and it is very important that they get the right sort of evidence.

“We already know that a copayment on GP visits will reduce utilisation and we know that patients are already deferring their visits to GPs because they cannot afford them. This will only exacerbate that situation.”

Adjunct Associate Professor Lesley Russell, from the University of Sydney’s Menzies Centre for Health Policy, said what concerned her was that evidence had already been provided to politicians and it had “changed nothing”.

“What is needed is strong, thoughtful leadership from the stakeholders, particularly doctors”, Professor Russell told MJA InSight. “They are the ones with the commitment to the patients, and they are the ones who see the bottom line. They see the consequences.”

Professor Russell coauthored an article in this week’s MJA asking what the Australian health care system could learn from the US. The authors wrote that there were positive aspects of the US health system that could be emulated in Australia, including trials of new models of health care to organise, deliver and pay for health care services so quality of care was rewarded over quantity of services, and physician engagement in reforms, such as trialling and implementing new payment models that are not fee-for-service. (1)

Professor Russell told MJA InSight there was one particular model of primary care in Australia that was working well — Aboriginal Community Controlled Health Organisations (ACCHOs).

“ACCHOs are community-based health providers [controlled locally]”, she said. “That’s what we should be doing more of [in non-Indigenous communities].”

Steve Milgate, executive director of the Australian Doctors Fund, said his organisation was “pleased” to see copayments being invested in a medical research fund. (2)

He said that as long as the safety net was available for disadvantaged patients, there was no problem with the $7 copayment.

“Many AMA members already charge a fee which involves a gap payment”, Mr Milgate told MJA InSight. “So copayments are already strongly supported by the medical profession.”

Mr Milgate said that Medicare “must be sustainable”.

However, Professor Jeffrey Richardson, foundation director of the Centre for Health Economics at Monash University in Melbourne, said that the claim that Australian health care was unsustainable was “unambiguously false”.

“As a percentage of gross domestic product, we spend 6.6% on health care — that’s the 10th lowest in the OECD”, Professor Richardson told MJA InSight.

“Our health bill is pretty typical for the Western world and it is sustainable”, he said.

Copayments would force patients to defer care until they needed a specialist or hospital emergency department (ED), Professor Richardson said.

“Specialists in this country are 2.5 times as expensive as GPs. And it’s unlikely that hospital EDs will charge a copayment because of the administrative burden. It puts hospitals in an invidious position.

“The problem has been that the government does not raise enough revenue. There are many good ways of increasing revenue that do not rely on [sick and poor people].

“You won’t get efficiencies from sick patients. They’re not in a position to judge what they need and what they don’t.”
 

1. MJA 2014; 200: 526-528
2. Australian Financial Review 2014; Online 13 May