Money not all an ailing health system needs
With a single announcement, a $2.3 billion pledge to cut out-of-pocket costs for cancer patients, Bill Shorten cast healthcare as a key battleground in the 2019 election.
The opposition leader has spent much of the past week spruiking his party’s health plan while on the campaign trail – on Wednesday he was in Midland Public Hospital in Perth, committing $20 million to a “Right to Trial” program, which would help blood-cancer patients access clinical trial drugs and therapies. On Thursday, he was in the Northern Territory, where he announced $115 million for programs to reduce the rate of suicide and other preventable diseases in Indigenous communities.
It is Labor’s cancer plan though, which Shorten announced before the election was called and described as the “most important investment in Medicare since Bob Hawke created it”, that has most animated the electorate and divided medical professionals.
Health Minister Greg Hunt labelled it an “irresponsible hoax” that would blow a $6.8 billion hole in the budget. But that $6.8 billion figure, it later emerged, was the Health Department’s costing of a separate proposal – requested by the government – to lift the Medicare rebates for all 420 cancer items on the Medicare Benefits Schedule (MBS) to match the Australian Medical Association’s recommended fees.
At a base level, with the incidence of cancer well known – 145,000 Australians are expected to be diagnosed with cancer this year – the cost of Labor’s scheme appears to be containable. And its goal is ambitious – to lift the rate of cancer specialists bulk-billing for consultations to 80 per cent.
“That’s pretty impressive,” says Grattan Institute health economist Stephen Duckett. “If the rate is one in five, it’s pretty hard to find a bulk-billing specialist for your consultation. If it’s four in five, it becomes the norm.”
Labor says the Parliamentary Budget Office has costed the proposal and projected that bulk-billing rates will rise to 85 per cent for oncologists.
However, the cancer plan doesn’t cover in-hospital treatment. It offers $433 million for a new Medicare item to cover the cost of seeing a specialist oncologist and surgeon, with a rebate payable if the service is bulk-billed.
There is limited evidence that more funding will encourage specialists to bulk-bill, and cynics within the medical community say it won’t have an impact. So, with private specialists free to set their own fees, Labor’s plan will hinge on expanding cancer services in public hospitals.
As part of Shorten’s plan, $600 million has been earmarked to support bulk-billing of scans for cancer patients, helping to shield them from out-of-pocket costs.
The Consumers Health Forum has reported that more than 25 per cent of cancer patients are more than $10,000 poorer in the past two years. Out-of-pocket costs for the two most common forms of cancer – breast and prostate – reach nearly double that amount for some.
As Duckett explains, concerned GPs and panicked patients often opt for private specialists with high upfront costs to avoid waiting lists in the public system. If Labor’s plan is achievable, it could significantly speed up diagnosis and treatment.
“That first consultation is critically important in terms of reassurance and a patient’s understanding [of] what is happening and getting the right treatment,” he says. “But is it going to fix every problem of out-of-pocket costs in the Australian health system? No, it’s not.”
Those costs are estimated at $34 billion a year – about a fifth of the nation’s total $181 billion health bill. The Consumer Health Forum’s chief executive, Leanne Wells, says the burden on Australian patients is among the highest in the OECD, and it causes people to delay or defer the treatment they need.
“We know that people are just not going to the GP, filling scripts, following up on specialist referrals, because of cost,” she says.
Leading doctors tend to see Labor’s cancer plan, announced in Shorten’s budget reply speech with reference to his own mother’s fight with breast cancer, as a clever tug on the public’s heartstrings. Cancer afflicts one in two Australians by the age of 85. But what about other patients with equally devastating health problems?
Instead of piecemeal measures and splashing cash for public hospitals, many doctors want to see a long-term plan to strengthen Medicare and new investment to withstand a significant load of chronic disease as the population ages.
Dr Harry Nespolon, president of the Royal Australian College of General Practitioners (RACGP), says politicians in election mode make a mistake by concentrating on what he calls the “expensive side of medicine” – pouring money into managing diseases rather than promoting health.
“As GPs, we are the ones who make the diagnosis of cancer most of the time, and we are the ones who are going to be taking care of the patient once all the expensive tests have been done, and yet there is no support in anything the Labor Party has said so far for primary care,” he says.
“We would say to both parties, get off the disease end of medicine and start talking about the care that people need every day to stop them from going to hospital and hopefully prevents them from getting cancers or [helps them detect] their cancers sooner.
“Unless the government is willing to really think hard about the best way to deliver healthcare into the future, they are not going to be able to build enough hospitals fast enough to deal with the ageing population.”
GPs are hurting after a five-year freeze on Medicare Benefits Scheme rebates, which was imposed by Labor as a temporary measure in 2013 and continued under the Coalition until a return to indexation this year. Despite the much-vaunted high bulk-billing rates for Medicare services, Nespolon says GPs have been forced to charge more patients in order to remain viable.
“We know that the gap for seeing doctors is increasing and under the current policy regime GPs as a group will fall $40 million behind every year, just because of inflation,” he says.
“As the average person would know, GPs are small businesses. If your costs keep rising at a rate greater than revenue, you either raise your rates – which we are seeing – or you go out of business, neither of which is ideal for the population.
“It will take $1 billion just for us to cover the Medicare freeze that both parties subscribed to from 2013 to 2018. Even if we got an extra billion dollars, we’d be just back where we started.”
In failing to invest in primary care, Nespolon says, Australia is a long way behind the likes of Denmark, where authorities have closed hundreds of hospitals in the past few decades, shifting the focus to primary care rather than relying on emergency departments.
The RACGP and the Australian Medical Association (AMA) have both welcomed the Coalition’s plan for a new model of medical care for Australians over 70 years old with chronic and complex diseases, which involves a $448 million measure to pay GPs to monitor and co-ordinate patient care, without the need for face-to-face consultations that are billed as fee-for-service.
“It is new in funding, but nothing new in terms of process,” says AMA president Tony Bartone. “It’s an acknowledgment of all the stuff we currently do that doesn’t require face to face.”
Speaking to The Saturday Paper, Taree doctor Simon Holliday lamented the poor access to health services in his electorate of Lyne, held firmly by the Nationals, which struggles with high rates of obesity, stroke and cardiovascular disease.
“Is it a public health risk to be in a safe seat? I think the answer is yes,” says Holliday, an addiction medicine physician and GP. “We don’t have the services because we are not politically inarticulate.”
In a video posted on Twitter last week, one of Australia’s most influential rural doctors, Ewen McPhee, stood in a paddock and squinted into the Queensland sun, demanding politicians “get over the rhetoric”.
“We’re about to face another election. And again the same policies, the same comments, the Medicare scare, the Medicare freeze, are being debated by our politicians,” the president of the Australian College of Rural and Remote Medicine and past president of the Rural Doctors Association of Australia said. “The fact is, our rural people need better access to care, we need adequate funding for our health services in the regions. And I call on all politicians to get over the political argy-bargy and just do what’s right for rural Australia.
“Fund Australian general practices properly. Look at real rebates for Medicare that address the costs of healthcare in the country. Give people fair access to health services.”
This article was first published in the print edition of The Saturday Paper on Apr 20, 2019 as "Shot in the arm". Subscribe here.