GP copayment should stay on the table

IN the 12 months to September 2013, the Australian Government spent over $6 billion on Medicare benefits for all GP services, providing 107 million bulk-billed services.

The lively 2013 debate about the introduction of a small patient copayment for a GP appointment raised the pressing question of whether Australia’s high level of Medicare funding delivered cost-effective care that improved acute and long term health outcomes. How does one approach the burgeoning cost and demand for general practice yet maintain similar or better care and patient satisfaction?

The $7 billion shortfall in public hospital funding that requires federal government bailout makes it worthwhile revisiting the introduction of a small copayment for a GP visit.

A patient charge for acute medical care in the United States in 1996 found that a US$35 surcharge reduced inappropriate emergency department use in 30 000 patients. This was most noticeable with low illness severity. There were no excess deaths and adverse events in the copayment group compared with patients who were not charged.

Imposing a small copayment might prevent visits to medical facilities for children with mild ailments, but is unlikely to deter attendance for severe symptoms, according to a recent Japanese study.

There are concerns that serious adverse health outcomes may occur in disadvantaged patients who may be dissuaded from seeking GP care if it becomes less affordable. The opportunity for early detection of serious illness is lost if a person delays or avoids a GP visit because of out-of-pocket expenses, according to an editorial written by Professor Christopher Del Mar and published in the MJA in 2014.

Del Mar is concerned about:

• copayment as a game-changing disincentive to visiting a GP;
• ambiguity surrounding “unnecessary” GP consultations; and
• continuity of equitable access to health care.

He argues that universal access to primary care is a fundamental provision of Australia’s Medicare and undoubtedly keeps the quality of Australian health care high, and contends that many inappropriate GP consultations serve to reassure the patient or parents of young children.

On the other hand, helping patients understand that their symptoms can be self-managed complies with a patient-centred approach. There are sustained health benefits from enhanced health education and promotion. Moreover, parents of young children value educational interventions that help them manage common minor symptoms and illnesses at home.

In a 1996 study conducted in California, the introduction of a copayment for the use of the emergency department reduced attendance by 15%, mostly among patients with minor illnesses. If one assumes that GP patients have much higher rates of minor illnesses when compared with emergency department arrivals, then a copayment is unlikely to “consign the poor to a safety net level of service, the quality of which will depend on the vagaries of the economy and electoral pressures, but will be second class”, as claimed by the Doctors Reform Society of Australia. (Out-of-pocket costs in Australian health care, submission 26).

The safety factor is that GPs already bulk bill patients with lower incomes, those with a chronic disease and holders of concession cards. It is suggested that these are the people who would be most disadvantaged by the introduction of copayments for GP visits.

A patient-centred care model requires GPs to be well placed to implement public health and preventive strategies that will reduce the 40% premature mortality determined by unhealthy lifestyle choices, and the 15% attributable to adverse psychosocial and family factors.

As GPs are central to ambulatory and long term care of their local communities, they need to understand and address the upstream determinants of downstream sickness. The health benefits to be gained from unsustainable Medicare funding for GPs is debatable.

We need to focus more on obesity, unhealthy eating, smoking, alcohol use and being sedentary. Public health prevention is better compared with costly medical care. The simple acts of living a healthy physical and psychological life, eating well, reducing stress and making the effort to stay active are a far better and safer strategy to delay the onset or mitigate the severity of chronic illness and debility.

However, modern urban life conspires against the successful uptake of such non-medical therapies. The frenetic pace of contemporary life allows us no time to exercise and tune-out. Cars are necessary to commute to work from distant suburban homes. We sit at our desks all day, come home to entertainment lounges and surrender to packaged meals that take next to no effort to get ready.

Let’s fund better urban planning that allows workers to live close enough to walk or cycle to work, fruit and vegetables that are more affordable than the convenient fast food, in addition to easy access to fitness centres and mandatory participation in exercise programs located in the workplace. We are then far less likely to need community or acute medical care over the long span of our lives.

In summary, general practice care could be improved in clinical outcomes and patient satisfaction if the Royal Australian College of General Practitioners shifts the emphasis to healthy habits through the course of a patient’s and family life.

There is no evidence that a small patient copayment poses the vociferously argued high risk of adverse outcomes from non-attendance or delays for GP care. A small patient pay-per-visit charge could become an added incentive for communities to stay healthy, engaged and safe.

Joseph Ting is an adjunct associate professor at Queensland University of Technology’s School of Public Health and Social Work and clinical senior lecturer in the Division of Anaesthesiology and Critical Care at the University of Queensland.

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