Category: Public Health

for new specialist technologies or treatments and an increased Medicare
rebate for GPs, up to $41.40 for a standard visit for a RACGP member,
which is 40.6% of the AMA fee. Doctors without the RACGP qualification
still get $21, which is 20.6% of the $102 AMA fee.
When Medicare was born, the Medicare rebate was 85% of the AMA fee.
The rebate has risen at half the inflation rate for 39 years, so doctors now
feel ripped off every time they see a Medicare patient. Labor blames the
disparity on the rebate freezes of the previous LNP Coalition governments,
but its own record is poor. Successive governments of all types have
deferred to the private health lobby and are starving Medicare, slowly
defaulting towards a principally private system, as in the USA. This is a
deeply-troubling prospect because the US health system has been
recurrently criticised (Commonwealth Fund 2021) – and rightly so –
because it makes access to health care dependent on ability to pay. Notably,
however, it is the world’s best system at turning sickness into money.
The other recent Labor ‘reform’ was to allow pharmacists to process
prescribed medications to cover patients’ requirements for 60 days, rather
than 30 days, thereby halving the costs of prescribing and dispensing.
While this may seem helpful, patients are often confused by complicated
generic names and generic brands; and compliance or discontinuation of
medicines is a largely unquantified problem. These are existing problems
with the current arrangements for dispensing medications: the recent
policy change, while well-intentioned, does not redress them. It transfers
resources from professional staff to the pharmaceutical industry.
The ‘Strengthening Medicare Taskforce’ had good medical and allied
health representatives and support. Its December 2022 report defined the
problems but, trying to avoid controversy, positive suggestions were thin
on the ground. A deeper analysis and more comprehensive approach to the
redress of health issues is needed.
Basic problems in the health system
Diverse funding sources causes cost-shifting
Fundamentally, no-one is in overall control of the health system. It has a
number of different funding sources: the Federal and State governments,
the Private Health Insurance industry (PHI), Medicare and individuals

themselves. Workers Compensation (WC) and Compulsory Third Party
(CTP) insurers also put in a bit. These arrangements lead to a situation
where each funding entity attempts to shift costs without any real care for
the overall cost of the system. Private entities such as pathology and
radiology also have an interest in providing more services, whether they
are needed or not.
The broad division of the health system is that public hospitals and
emergency departments (EDs) are State-funded, and non-hospital services
are Federally, PHI or self (patient) funded. There is some overlap,
however, because the State’s provision of some community-based services
allows them to save on hospital-bed days; and private funds paid to State
hospital in-patients are eagerly sought. The starvation of Medicare (which
reduces the Federal government’s spending) has resulted in more patients
going to EDs at higher (State) cost, as well as increasing PHI and patient
costs.
This cost-shifting has evident implications for the affordability of health
care: notably, a recent study showed that Australia, when compared to 10
other countries, scored poorly on its measure of affordability
(Commonwealth Fund 2021).

A new health paradigm is needed
Yet more fundamentally, there is a huge problem with the conceptual
model of the health system. In common parlance, the ‘health system’ is the
‘paying to treat illness’ system. Paying doctors to see and treat patients is
seen as the major cost and is the most politically fraught element in the
system.
Historically, everyone was assumed to be healthy and had episodes of
either infectious diseases or surgical problems. They went into a hospital
for a brief period and either recovered or died. The legacy of this is that
heroic interventions are over-resourced and the more cost-effective early
interventions are under-resourced.
Infectious disease is now relatively uncommon, notwithstanding the recent
and ongoing coronavirus concerns. Most disease is chronic; and the
objective is to maintain health for as long as possible and to support those
who need support in the community rather than in institutions. ‘Health’
must be re-defined as a state of physical and mental wellbeing; and
maintaining it as ‘demand management’ for the treatment system.

Life-style diseases of diet, obesity, smoking, vaping, alcohol, drug-use and
lack of exercise need attention. It might be commented that these habits
are more determined by the political economy of the products than by any
health considerations; and the government should intervene to re-balance
this market failure.

Hierarchies, cartels and corporatisation
The medical system is hierarchical with specialists at the top and GPs at
the bottom. The specialist colleges have produced less practitioners than
would have been optimal. The starvation of General Practice has led to
increasing specialist referrals for simple procedures. Most patients are
happy to go along with this, though often much less happy about the rising
costs. Practitioners tend to work down to their station rather than up to
their capacity. GPs, if given the appropriate additional education and
empowered to act, could do what quite a lot of specialists do now, while
nurses could take the load from GPs; and, in terms of home support, a more
comprehensive and flexible workforce needs to be developed.
Private medical insurance systems are a further source of problems. They
have marketing, churn, profits, liability and fraud issues; and they make it
necessary to account for every item of every procedure. While the
corporations watch every cost, the regulator cannot. Corporations buy
medical practices and take up to 55% of the gross revenue. Smaller
radiology practices are being gobbled up as investments (Cranston 2020).
If overheads are defined as the amount of money put in compared to the
amount paid for treatments, Medicare costs about 5% and PHIs, as they
are regulated in Australia, about 12%. In the USA, the private health funds
take up to 35%, and Australia’s CTP system got close to 50%. A universal
health insurance system could avoid many of these costs and would be far
superior from a social equity point of view.
Similar problems are evident in the provision of care for people with
disabilities. Labor pioneered the NDIS when last in office a decade ago,
and rightly claims this as evidence of its commitment to redress the
previous neglect. However, the NDIS can be considered as a privatisation
of the welfare system. It overlaps medical system functions and is poorly
regulated. If its efficiency is judged by the percentage of money put in that
is paid to the actual workers delivering the service, care is not very