GP co-pay: where is the data?

The Australian Medical Association (AMA) and the Australian Healthcare and Hospitals Association (AHHA) have both hit out at the lack of evidence or data modelling underpinning the federal government's plans to introduce a $7 co-pay for GP consultations and pathology and diagnostic imaging tests.

In a strongly worded opinion piece in Fairfax newspapers today, AMA president Brian Owler criticised the measures as bad health policy and said healthcare was too important to become “an ideological toy”.

Dr Owler also criticised the lack of evidence for the co-pay policy, arguing that the cost would deter vulnerable patients from visiting their doctors and that available figures show the health budget is not out of control.

“The recent COAG Reform Council report showed that, among the more disadvantaged in society, 12 per cent of people defer or do not see their GP due to cost,” he wrote. “It will significantly increase with a co-payment.

“The health budget is not out of control. As a proportion of GDP, Australia’s healthcare spending has remained constant.

“Modern medicine is evidence-based. We are trained not to accept blind assertions or opinion, or indeed ideology, in determining the best treatment without the supporting evidence.

“The AMA is supportive of some co-payments, but not the one proposed by the government.”

The AHHA has also criticised the lack of modelling undertaken by the government in developing the policy as well as its claims that states were overstating hospital activity.

In a statement, the AHHA quoted Health Minister Peter Dutton's remarks to the National Press Club last month in which he claimed that modelling showed there would be an increase in the number of GP presentations over the course of the next couple of years, necessitating the introduction of a co-payment as a price signal even though it would only reduce GP visits by less than one per cent.

“There will be, on the modelling that we've done so far, an estimate around one per cent of people who won't present to general practice, and we say that in year two that drops off to about half a per cent,” Mr Dutton said.

However, a freedom of information (FOI) request by The Australian newspaper's health editor Sean Parnell for any documents showing the modelling done by the Commission of Audit regarding co-payments for medical services and the PBS – Mr Dutton has been using the commission's recommendation of a $15 co-pay to bolster his argument for a lesser co-pay – was rejected by the Department of Health as it could find no such document.

The department told The Australian that “an extensive search and consultation with the relevant policy areas revealed that there are no documents (summary or otherwise) held by the Department arising from all modelling conducted under the current government regarding co-payments for medical services, as recommended by the Commission of Audit and detailed in the Budget, and increased co-payments under the Pharmaceutical Benefits Scheme.”

The AHHA itself has requested information from the Department of Human Services through FOI on the number of people who were bulk billed in 2012-13 to attempt to find out the difference between that number and the proportion of services that are bulk billed.

That FOI request was also rejected “on the grounds that the information did not exist and that to produce it would require the development of a computer program”, the AHHA said.

The AHHA said that given that this policy measure was a fundamental change to bulk billing practices, “it is extraordinary that data required to understand the number of people who will be affected by the policy has not been developed, and that the limited bulk billing data that is available has not been used to model impacts”.

AHHA CEO Alison Verhoeven also pointed out that health department officials had told Senate Estimates hearings a fortnight ago that the department had not undertaken any modelling on the effect of the co-payment on public hospital emergency departments.

“[The Health] Minister has stated that Department of Health modelling suggests that the co-payment will stop only 1% of people going to the doctor in the first year of operation,” Ms Verhoeven said.

“Given that there is no data currently available on the number of people that are bulk billed, we would be very interested to learn how this estimate was developed.

“The co-payment policy is rapidly becoming an evidence-free zone, with the Commission of Audit claims about GP attendance rates being disproved, no apparent efforts made to model the potential impact, and no baseline data available to evaluate its effect over time.”

She also took issue with Mr Dutton's statement defending funding cuts to hospitals for achieving the National Elective Surgery Target and the National Emergency Access Target because the government “did not support incentive payments as states had been overstating hospital activity”.

“Given the rigour applied to the analysis of hospital activity data by the Independent Hospital Pricing Authority, the Australian Institute of Health and Welfare and the National Health Funding Body, this will come as a surprise to the states and territories and we would welcome the opportunity to examine the evidence that the minister has available to him,” Ms Verhoeven said.

In his opinion piece, the AMA's Dr Owler also criticised the effect the co-pay would have on pathology and diagnostic imaging practices. He said it would be logistically impossible for many pathology labs to collect the co-pay as many didn't actually see the patient in person.

“In diagnostic imaging, the issues are even more significant,” he said. “The loss of the 10 per cent bulk billing incentive, as well as the $5 rebate cut, means that radiologists face much greater losses.

“The patient will have to pay the whole amount for the test and claim the rebate afterwards. Diagnostic imaging practices providing excellent services in disadvantaged areas will become unviable.”

The Australian Diagnostic Imaging Association (ADIA) said that in its view, the government has been too aggressive on patient rebates for diagnostic imaging.

“Many people will simply be unable to afford it under the measures announced in this budget - especially if they have to pay the full cost up front - and many conditions will therefore go undiagnosed,” it said.

The RACGP also opposes the co-pay in its current model, with president Liz Marles saying the college had not been consulted on its introduction and that she did not believe the government had any understanding of the practical implications for general practice in administering the fee.

“They have talked about an additional $2 to GPs, where there is a $5 cut in the rebate but a $7 co-pay and they say you'll be $2 ahead,” Dr Marles said.

“In fact, the bulk billing practices will have to install a billing system or to collect cash and also to train their staff, and there is more staff time involved [in collecting it]. There's an estimate that's about $2.54, so you are behind from the outset, and that's not even taking into consideration any patients for whom you may wish to waive the fee."

The Rural Doctors Association of Australia (RDAA) is particularly concerned about the lack of clarity on how doctors are supposed to collect the payment from people in aged care facilities or palliative care patients.

RDAA president Ian Kamerman said the co-pay model would hit rural patients hard and cause significant problems to country medical practices and their communities.

Dr Kamerman said many other questions about the co-payment remain unanswered. “For example, what will happen with an elderly patient who is in a nursing home and incapable of managing their finances?” he said.

“Or the dying patient in the final weeks of palliative care, who is seen by the doctor at home? Is the GP really expected to collect seven dollars from these patients before providing treatment?

“The federal government has made it clear that one of the aims of the co-payment is to curb demand for services. However, over-servicing of aged care and palliative care patient populations is very rare.”

Posted in Australian eHealth

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