Impacts of Inequality
In 1971, Dr Julian Tudor Hart, a general practitioner from the United Kingdom, produced a seminal publication in the Lancet where he defined the Inverse Care Law. According to this now well established principle, the availability of good medical care tends to be inversely related to the need of the population. Subsequent study of the theory has shown that where market forces are strongest, this Law delivers the most distortion in healthcare provision. In Australia, we have a universal healthcare system made possible by Medicare subsidies. However, our general practice provision is almost entirely delivered by independent, profit seeking businesses. Therefore, whilst Medicare alleviates the cost of accessing care for our poorest and most complex patients, the market is still able to profit most in populations where there are more “worried well” who can pay significant out of pocket costs. This means that practices where more than half of patients seen contribute a co-payment, the number of patients seen per hour falls to around four. In catchments almost entirely bulk billed, where Medicare is the sole source of payment, the number of patients seen per hour averages seven.
Across the world, poorer communities tend to have far higher rates of chronic disease and disability. Australia’s Health Tracker 2017, issued by the Australian Health Policy Collaboration, found that people in the two lowest socio-economic quintiles are at much greater risk of poor health. For example, they found the most disadvantaged 20% were 60% more likely to live with diabetes than the most affluent 20%. Obesity is 57% less evident in the most affluent catchments than the poorest. Suicide rates produce the starkest contrast. They are 71% higher in the lowest quintiles than in the most prosperous. It is estimated that combinations of such factors means an extra 50,000 people in the poorest catchments have died before the age of 75 over the last four years. This reality creates additional carer responsibilities and grief in already struggling communities.
With such sobering statistics to hand we need to see change in how healthcare is delivered in Australia. The patients seen by general practitioners in communities like Inala, in the bottom 10% of incomes nationally, will be far more complex than average. Yet, reliance on Medicare payments to cover costs of care means practices across this catchment schedule more patients per hour. In our local community many practices run diaries based on eight appointments per hour rising to as many as 12 per hour on weekends when doctors are most scarce. This is clear evidence of the Inverse Care Law in action. Another example of its application is the distribution of doctors, nurses and allied health providers. In communities where bulk billed care is the dominant model very few psychologists, podiatrists, practice nurses and Australian trained doctors can be found. For these reasons, Inala Primary Care often has patients sent to it by surrounding GPs who believe the patients have become too complex to service in a commercial GP practice. This means our practice patient average age is late 50’s when the average age of a Queenslander is mid-30’s. It also means over 40% of our patients have refugee backgrounds, with one in seven needing an interpreter to discuss their health with a doctor. Such consultations are very slow, moving our practice further away from the prevailing business model of seeing eight patients per hour. We never book more than four as our doctors would simply run too far behind.
The government releases statistics on bulk billing each year to show that the freeze on Medicare has not affected the provision of healthcare. Sadly, these statistics do not paint the whole picture. In consultations with complex patients a number of item numbers are often billed for example a consultation item number and a bulk billing subsidy item number of just $7.30. This means the average bulk billed consultation delivers just $44.35 yet equates to two bulk billed items. The Australian Medical Association recommends general practitioners charge $78 for this work, a difference of $33.65. Very many metropolitan practices charge over $80 for this type of consultation due to higher rental costs. So rather than releasing the percentage of item numbers bulk billed, the government should be discussing how many consultations or episodes of care were in fact bulk billed. This will result in a number far less than the 82% discussed in the media. Doctors simply cannot afford to run their practices reliant on bulk billing unless they increase the numbers of patients seen each hour…a bad outcome for complex and disadvantaged patients in communities like Inala.
There has been a freeze on Medicare indexation since 2014 and this is set to continue until 2020. That is six years with no change in rebates, an effective loss over this period of close to 20% of income according to Prof Stephen Duckett at the Grattan Institute. For a practice of our size, that equates to an effective loss of income of around $495,000 this financial year. Many of our staff are low paid administrative support and Enrolled Nurses. They have had no meaningful pay rises over this time and on hourly rates of less than $25 per hour, they are finding their incomes very squeezed. Work in hospitals and other care providers would offer an immediate boost to their incomes of over 30%. This is tough when their business is to care for some of society’s least wanted.
Finally, there is one last way that inequality shows itself in a disadvantaged catchment like Inala. Our patients are almost certain to have no private health insurance. With 49% of our patients living in the bottom 10% of income earning households in the country and two thirds in the bottom 20%, they simply have no capacity to pay to see a private specialist. That means they sit on public hospital waiting lists, often for years. In the meantime, their GPs are forced to try and do their best to keep them well. Delays like this increase the stress and risks our doctors’ face on a daily basis…and we ask them to do this for half of the fee recommended by the AMA!
To address the systemic disadvantage Medicare delivers in our community we need your help. We need advocacy for new funding streams to better support those frail aged, immigrant background or mental health patients we routinely see. We have less than 20 patients who identify as indigenous so we cannot access the “Closing the Gap” funding available to that needy part of our society. We need an equivalent policy and funding framework to ensure that 10 million of Australia’s people do not fall further behind and create the rifts in communities which breed hopelessness and violence. To help us with our advocacy for the cause, we need data and time to present it to decision makers. Your donation will help us make the case for the voiceless whose very lives are caught up in the Medicare debate.
We also need funding to support the social care programs which will stop very many of our patients presenting for healthcare. Too often we see challenging, stressful lives leading to reduced capacity to care for personal health. We see poor nutrition caused by rents taking the majority of incomes away from food and basic household needs. We see social isolation leading to reduced confidence, a perfect breeding ground for domestic violence and inter-racial conflict.
Inala Primary Care is a charitable general practice which reinvests any surplus income into designing new approaches to care and support. We know if we can make a difference to our patients, others can adopt our models to vastly improve the lives of the growing numbers of elderly and chronic disease patients in our society. Their health trajectory means our national expenditure on health will continue to rapidly exceed the milestone 10% of GDP reached in 2016. With more than one million invoices now sent to Medicare each day, we all have a vested interest in health reform.