Brendan Nelson, like any party gate-crasher, has made some uncomfortable comments. He brought with him to the party views he holds as president of the Australian Medical Association, calling for the end to universal bulk-billing. In John Hewson’s time the Liberal Party agreed with that. Now it has put changes to bulk-billing in the same category as the GST _ wash your mouth out. As things stand, universal bulk-billing is here to stay _ a Hewson-made untouchable. Nelson’s erstwhile colleagues dislike bulk-billing because it put competition in their ranks. While ever some doctors were willing to bulk-bill all patients, they would attract the custom. They would also save a lot of administration costs. The Nelson episode is one of several in recent times that show Australia’s health system as a jumble of fiercely competing interests and shifting alliances of convenience.
The main players are: the doctors (roughly dividing into four groups: specialists, AMA-type GPs, Doctors Reform-type GPs, and young salaried doctors); state Governments; the federal Government and the health insurance funds. State Governments want to present electors with well-run hospitals. From their perspective any unduly long waiting lists are due to: lack of federal funding; monopolistic practices by specialists whose colleges refuse to let more practitioners in; declining private insurance due to federal government policies. State Governments play various tricks against the Federal Government to extract more money (and deny all of them). They fail to give information on waiting lists. They give preference to private patients in public hospitals (or allow doctors to) because private patients pay more. They try to pressure people into going to GPs rather than public hospitals for all but catastrophic emergencies. This way the Federal Government through Medicare pays. The Federal Government wants to present electors with low-cost universal health insurance. In its view waiting lists are due to state-government incompetence in running hospitals and high medical costs are due to doctors’ greed. Only bulk billing is saving us from unbridled excess. It plays various tricks in presenting a picture of efficiency.
The most significant is that the Medicare levy is 1.5 per cent of income, but the real cost of health has been estimated at between five and 10 times that. It refuses to do anything to encourage private insurance _ rather letting it go in free fall with higher risk people staying in so premiums go ever higher. The Government refuses tax deductions and insists on a community rating so the funds have to charge the same premium irrespective of risk. The only value in private insurance is to avoid waiting lists at public hospitals for non-urgent surgery. It is worse than useless for urgent treatment or treatment for a range of serious illnesses which are treated almost solely in public hospitals. In these cases private patients come out with a bill having been treated in exactly the same way as public patients who get treatment for nothing.
The insurance funds want to present private insurance as the most efficient way to finance health. But they want the Government to pick up all the chronically ill, the expensive treatment for catastrophic illness that only public hospitals can treat, and all the people too poor to pay private-insurance premiums. They also want different premiums for people with different risks. Until this year they have nearly always sided with the doctors, but had a major falling out over the Federal Government’s latest attempt to stem the slide from private insurance. The funds, doctors and hospitals will now be able to negotiate treatment deals.
It will mean 100 per cent coverage, a complaints system and funds requiring continuing education, but patients will be forced to certain doctors or hospitals if they want benefits. Some specialities have rejected the idea. The doctors like to present a view of putting the patient first. That view neatly coincides with opposition to any cost control because that is not in the best interest of the patient. Over-servicing, of course, is caused by lawyers geeing up patients to sue unless every conceivable test is done. Overall, the picture appears to be one of endless squabbles and compromise. However, the tension and competition between the parties has had quite a good outcome. It is not perfect by any means, but the following are pluses.
Perhaps only parts of the US (if you are very rich) give better treatment and perhaps only parts of Europe, Canada and Britain give equal treatment. Only Britain and parts of Europe give treatment as universally. Only Britain and parts of Europe spend less on health for similar outcomes. People with urgent or catastrophic illnesses are generally treated well irrespective of income. Non-urgent cases have to wait but are not refused. Fortunately, medical mistreatment or non-treatment resulting in death or harm is unusual enough in Australia to make the stuff of headlines and television news bulletins.
The down side is that entrenched ideology has prevented some obvious reforms to cut costs and over-servicing and to encourage more private money into the system. For example, there is no reason why patients should not be able to swipe the Medicare card at all surgeries and pay the balance in cash, instead of paying the whole bill and getting a refund. If swiping the card is an efficiency for bulk-billers, why not apply it to all? An insistence on some co-payment for every visit by all patients would cut over-servicing.
It worked with the Pharmaceutical Benefits Scheme. And risk rating for insurance would bring the healthy and young back into private insurance. They would pay for a rainy day, but prefer to take the risk if they are forced to pay the same rate as the old and infirm. If these things are to go on the agenda it may take a little more party gate-crashing and political ambivalence such as provided by Nelson to stir the debate.