13th February 2019, Dr Chee L Khoo
One of the great advantage of being a runner is that wherever you go, all you have to do is pack a pair of running shoes and the world is your oyster. During a recent visit to Kuala Lumpur, Malaysia, I went out running on the local streets. It was 6am and still pitch dark. One of the stretches of road I ran on was a bit narrow, so I thought it would be safer to run on the pavement. After all, that’s what pavements are for.
20 minutes into the run, I ran into a big hole. One of the manhole covers covering the underground drain was missing and I just dropped into the hole. I sustained a deep macerated laceration over the shin. Unfortunately, despite a thorough cleaning of the wound and prophylactic oral antibiotics, I developed cellulitis by day 3. This necessitated 4 courses of intravenous ceftriaxone.
I returned to the scene of the accident the following morning and was aghast with what I saw in broad daylight. There were at least a dozen deficient manhole covers along that short stretch of road.
Pedestrian pavements play an important role in providing a safe path for people to walk on. They aid road safety by minimising interaction between pedestrians and motorised traffic. Unfortunately, if the community cannot be assured that pavements are “always” safe to use, then they won’t be used.
It’s expensive to build pavements for pedestrian use. But if they are so poorly maintained that they are known to the local community to be dangerous and they avoid using it then whole purpose of building pavements is not realised. In the end though, residents still walk on the road and are in danger of being run over by motorised vehicles. It’s a lose-lose situation.
So, what does that have to do with Medicare? Medicare began life as Medibank in 1975. Successive governments tinkered with it but basic tenets remain the same. Medicare was intended to provide the ‘most equitable and efficient means of providing health insurance coverage for all Australians’.
Medicare is a publicly funded universal health care system. The WHO describes UHS as “a health care system that provides health care and financial protection to all citizens of a particular country. It is organized around providing a specified package of benefits to all members of a society with the end goal of providing financial risk protection, improved access to health services, and improved health outcomes.”
Universal health care does not imply coverage for all people for everything. Universal health care can be determined by three critical dimensions: who is covered, what services are covered, and how much of the cost is covered.[1] It is described by the World Health Organization as a situation where citizens can access health services without incurring financial hardship.
Well, that is the intent when Medicare (Medibank) was first introduced. Both political parties argue that they are upholding the principles of Medicare. Both argue vehemently that Medicare still exist. Does it? We all know that:
- Under-investment in the public health system has meant increasing pressure on the public system to accommodate those that are not able to afford the private system
- Failure to rationalise and modernise the public health system has led to more and more inefficiencies, duplication and wastage in the health system
- Clinicians are increasingly asked to prop up the system leading to clinician burnout. Many of the more experienced clinicians are leaving the public system in droves
- Loss of trust and goodwill between government and clinicians over the decades have led to mutual suspicions with each doing their own thing
- Rebates that are forever shrinking and frozen have led to struggling practices. Sadly, clinicians now have to spend increasing time and effort chasing after the buck instead of looking after patients. We should be doing what we know best – looking after patients.
- All these are occurring when there is increasing paperwork and workload on compliance. Increasing proportion of our time is pre-occupied with meeting endless and meaningless paperwork. We are all expected to jump over hoops to meet artificial targets.
- Over the last 10 years, there has been significant technological change in the way practices are run and connected. Yet, we have not been consulted nor funded to keep up with technological change. The digital transformation is leaving many clinicians behind.
- Medicare is said to still exist but really, it is just the concept, the idea that remains. Australia has one of the highest out of pocket medical expenses in the developed world (apart from the US). While most GPs still bulk bill, most specialists no longer universally bulk bill.
- So, what does all these mean for patients? Increasingly patients are avoiding seeing their doctors (mainly specialists) because they are not able to afford the out of pocket expenses. An average visit to the specialists these days can cost up to $150-200 for the visit plus another $400-800 more if there are other tests ordered. Once again, Medicare have not kept up with the cost of many of the newer scans and tests and patients end up having to fork out hundreds or thousands just to have essentially tests. These are not fancy investigations but standard investigations that are listed in national and international guidelines.
- Public outpatients usually have a ridiculously long waiting list to see the specialist or when they are seen, there is a further long wait for the procedure in the public system. Not uncommonly, one has to see the specialist in the private rooms to be placed on the public waiting list. As they are not generally bulk billed, there is a significant out of pocket expense which many patients are unable to afford.
Early diagnosis and early management mean reducing mortality and morbidity. Medicare is supposed to improve access to medical treatment for all Australians and the current state of Medicare is certainly jeopardising this intent. It also makes life as a GP so much harder as we are left managing patients which we are less equipped to looked after because patients just simply can’t afford to go to see the specialists.
So, the state of Medicare as it stands now is exactly what a poorly maintained pedestrian walkway is. They both exist but nobody is served by them. The intent of both are not realised. Pedestrians will still be walking dangerously on busy roads as the poorly maintained pavements are dangerous and therefore under-utilised.
Patients are supposed to be well served under Medicare but Medicare has failed to “improve access to health services without incurring financial hardship”. Sadly, health is not on the priority agenda of either political parties in this coming election.