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Are concessional patients over-using Medicare?


The recent budget proposed measures which are intended to reduce demand on health services, particularly GP services, because of concern free or low-cost services are being over-used and a price signal is needed to keep Medicare sustainable (see Box). Reducing unnecessary GP visits could reduce costs to government and free up resources to treat higher need patients. Evidence suggests that concessional patients use GP services at a higher rate compared to non-concessional patients. A key question is whether the higher use of medical services among concessional patients reflects a genuine need for a health service or that health services provided to this group tend to be free or low-cost, and so they make unnecessary visits for trivial or non-existent conditions.

Answering this question is difficult because of the problems encountered when trying to determine the rate of unnecessary GP visits. A previous Flagpost has noted that it isn’t always possible to predict whether a medical visit is clinically necessary or not and patients are not always in the best position to determine this themselves. Other evidence needs to be scrutinised to determine if concessional patients are using health services unnecessarily. 

Box: From July 2015, each bulk billed GP visit, pathology or Diagnostic Imaging (DI) service will attract a $7 patient co-payment. Bulk billing is where the doctor receives the patient’s Medicare benefit as payment, and the patient pays nothing. After ten visits in a calendar year, the co-payment for concessional patients and children can be waived. Doctors will receive a low gap incentive payment to encourage them to bulk bill these patients, and to waive the co-payment after ten visits. Some chronic disease and health assessment services will be exempt. 

 

According to advice provided to a recent Senate Estimates Committee (see p. 65 of transcript), concessional patients visit GPs three times more often—on average nine times a year—than non-concessional patients. They also have more pathology tests (3 compared to 1.4 for non-concessional patients) and more imaging services (1.0 compared to 0.8).

There is other evidence to show that concessional patients are generally high users of health services. Nearly 88 per cent of prescription medicines dispensed under the Pharmaceutical Benefits Scheme (PBS) are for concessional patients (Expenditure and prescriptions, table 1(b)).

While there is no published data on the number of concessional patients who are bulk billed, bulk billing rates tend to be higher in regions of socio-economic disadvantage. While the national bulk billing rate for GP services is around 83 per cent, in electorates with lower average incomes and large numbers of concession card holders, GP bulk billing rates are high, while in regions with higher than average incomes bulk billing rates are lower. For example, Chifley in western Sydney has a bulk billing rate of 99.1 per cent, while in Warringah around 63 per cent of services are bulk billed.

30.5% of GP visits are made by those 65 or older, according to General Practice Activity in Australia (table 6.1), and 85% of those in this age group receive either the Age Pension or the Commonwealth Seniors Health Card, according to the last FaHCSIA annual report (p. 63). The proportion of the population having a chronic disease increases with age, as do the proportions of people reporting more than one disease.

Links between the health status of individuals and income, education and social exclusion levels are also well-established. Data shows that disadvantaged individuals are more likely to suffer chronic conditions, have more risk factors for chronic diseases and face financial barriers to health care. A recent report from the Council of Australian Government’s Reform Council found that rates of type 2 diabetes are nearly three times higher in the most socio-economically disadvantaged areas, compared to the least disadvantaged areas (Figure 2.6). The same report also found higher rates of smoking (up to five times higher for men, see Figure 2.2) and obesity (Figure 2.3) in disadvantaged areas compared to the least disadvantaged. A quarter of those living in the most disadvantaged areas reported not seeing a dentist due to cost, compared to 12 per cent of those in the least disadvantaged areas (figure 3.6) 

The advice provided to the Senate Committee also highlighted the higher use of pathology and diagnostic imaging (DI) services among concessional patients. The ordering by a GP of a pathology test and/or DI indicates that in their professional opinion, further clinical investigation is needed, which would be unlikely if the doctor believed the illness was feigned or trivial. That the rate of such tests is higher among concessional patients is also consistent with the higher rate of PBS prescribing and higher rates of chronic disease among this group.

If over servicing due to unnecessary visits is occurring (which is extremely hard to determine) there is little evidence to indicate that bulk billed concessional patients would be the main drivers of this. There is evidence that concessional patients are high users of health services, but that appears to reflect their poorer health status.