Bills Digest No. 85 2003-04
Health Legislation Amendment (Medicare) Bill
2003
WARNING:
This Digest was prepared for debate. It reflects the legislation as
introduced and does not canvass subsequent amendments. This Digest
does not have any official legal status. Other sources should be
consulted to determine the subsequent official status of the
Bill.
CONTENTS
Passage History
Purpose
Background
Main Provisions
Concluding Comments
Endnotes
Contact Officer & Copyright Details
Passage History
Health Legislation Amendment
(Medicare) Bill 2003
Date Introduced:
4 December , 2003
House: House
Portfolio: Health and Ageing
Commencement:
The day of Royal
assent
To:
-
establish a concessional safety-net for out-of-pocket costs for
'out-of-hospital' medical services;
-
establish a family tax benefit (A) safety-net for out-of-pocket
costs for 'out-of-hospital' medical services;
-
establish an extended general safety-net for out-of-pocket costs
for 'out-of-hospital' medical services.
Medicare is the Commonwealth funded health
insurance scheme that provides free or subsidised health care
services to the Australian population. It covers medical and
diagnostic services supplied outside public hospitals by general
practitioners and a range of specialists. Under Medicare
arrangements,(1) free services are also provided in
public hospitals to people who choose to be treated as public
patients.
The subsidy or rebate paid for a service under
Medicare is based on the Schedule fee that the Commonwealth sets
for that type of service. Under existing arrangements, doctors are
paid a rebate of 85 percent of the Schedule fee for an
out-of-hospital service and 75 percent for a service provided in
private hospitals.
There are currently three ways of billing
under Medicare.
- Patient Billing: Patients can pay
the doctor's account for the service and then claim reimbursement
from Medicare at the amount of 85 per cent of the Scheduled fee for
that service (ie., claim the Medicare benefit ). Any amount paid by
the patient above 85 per cent of the Scheduled fee will be an
out-of-pocket expense for the patient.
- Pay Cheque to Doctor: Patients can
obtain a cheque from Medicare, payable to the doctor, for the
rebate amount appropriate for the service provided (85 per cent or
75 per cent of its Scheduled fee). If the price charged by the
doctor for the service is higher than this amount, the patient must
pay the balance as an out-of-pocket expense.
- Bulk Billing: Medical practitioners
can directly bill Medicare for a service, accepting the Medicare
rebate as full payment for the service.
Under the bulk-billing arrangements no
additional charges relating to a bulk-billed service may be made,
consequently there are no out-of-pocket expenses incurred by the
patient. Generally, when a Medicare service is not bulk billed, it
is because the practitioner is charging more than the Medicare
rebate.
Further detail about the operation of Medicare
can be found in the Parliamentary Library publication
Medicare - Background Brief.(2)
The purpose of a health insurance scheme like
Medicare is to ensure as much as possible that a person s access to
medical care does not depend on his or her capacity to
pay.(3) The availability of bulk-billing plays an
important role in Medicare achieving this purpose. In recent years,
however, there has been a consistent decline in the rate at which
services have been bulk-billed, particularly among GPs.
Correspondingly, there has been an increase in patient-billed
services, where patients have been asked to contribute a payment
for their medical services. The following outlines these recent
trends in bulk-billing and patient payments.
Figure 1 below shows the increase, plateau and
then decrease in the proportion of GP services bulk billed between
1984-1985 and September 2003. The decrease has been occurring since
1996-97, but has become steeper since 2000. Between June 2000 and
September 2003, there has been a 10 per cent drop in the proportion
of GP services bulk billed.(4) This suggests that the
decline is gaining momentum.
Figure 1
There has also been a recent decline in the
overall proportion of specialist and diagnostic services that have
been bulk-billed. As Figure 2 below indicates, the rates of
bulk-billing for such services were generally never as high as for
GP services, and the decline (which only began after 1999-00) has
been less pronounced. There is also considerable variation between
non-GP services. While the bulk-billing rate for pathology
services, for instance, has increased 10 per cent since 1994-95,
the rate for obstetrics has almost halved.
Figure 2
The limited data
available indicates that there have been decreases in the rates at
which concessional patients (holders of a Health Care Cards,
Pensioner Concession Cards, or Commonwealth Seniors Health Card)
have been bulk-billed for the GP services they access. Between the
2001 and 2002 calendar years, there was a 5.7 per cent decrease in
the proportion of GP services bulk billed for concessional
patients, with a slightly greater decrease in metropolitan areas
(-5.7 per cent) compared to rural (-5.2 per cent).(5)
Bulk billing rates were, nonetheless, relatively high for
concessional patients for both years (86.4 per cent and 80.7 per
cent respectively).
Longer term data
specific to concessional patients is not readily available.
However, the percentage of GP services bulk-billed for patients
aged over 65 years has dropped 8.3 per cent from 86.9 per cent in
1996-97 to 78.6 per cent in 2002-03 (to March).(6) This
compares with a decrease of 10.4 per cent in the same period for
the rest of the population (from 78.9 per cent to 68.5 per
cent).
Clearly, a
decrease in bulk-billed services will mean an increase in the
proportion of services where patients incur out of pocket costs
(through being charged more than the Medicare rebate for the
service). But there has also been a steady increase in the average
amounts that patients have paid for non-bulk-billed services.
Figure 3 shows the rate of increase in average patient payments for
non-bulk-billed services since 1984/85.(7)
Figure 3
For GP services,
patients contributed an average $2.86 per service in 1984/85,
compared to $12.90 in 2002-03. For specialist and diagnostic
medical services the average out of pocket expenses have been
greater, as has the rate of increase. Department of Health and
Ageing figures indicate that in 1984/85, patients contributed an
average $5.03 to non-GP services, and by 2002/03 the contribution
had increased 310 per cent (in real terms) to $41.82.(8)
Figure 4 represents the difference in average patient contribution
between GP and non-GP specialist and diagnostic services (out of
hospital). It is likely that the increase in average patient costs
for specialist and diagnostic services is due to the greater
provision outside the hospital setting of complex procedures which
increasingly use advanced and expensive technologies.
Figure 4
These trends in
patient contributions suggest that patients are at increasing risk
of incurring out-of-pocket expenses for their visits to the GP and
to specialists, and at risk of those expenses becoming increasingly
high. Given the lower bulk-billing rate and higher average patient
contributions for specialist and diagnostic services, people
accessing these non-GP services are at particular risk of incurring
high out of pocket expenses.
It is within the context of this decline in
bulk billing that a debate about the future of Medicare has arisen,
and it is with the stated aim of fixing this problem that the
Coalition Government has presented its 'MedicarePlus'
package. There has been considerable debate, however, as to how the
problem might best be fixed, and what the factors are that lie
behind the decline in bulk-billing, particularly in relation to
GPs. Explanations of this have tended to centre around two views.
One focuses on the level of the Medicare rebate to doctors, and the
other focuses on the geographical distribution of GPs.
Medical practitioners have argued,
particularly through the AMA, that GPs are increasingly charging
patients more than the Medicare rebate for consultations because
the Schedule fees against which that rebate is set, does not
provide sufficient recompense for providing those
consultations.(9) The Federal Government, however,
argues that a decline in bulk-billing rates in an area is a
consequence of an under-supply of medical practitioners in that
area. Underlying this is the view that competition between GPs
providing services is a major influence on the number of services
that they bulk bill.(10) The Parliamentary Library
publication: The
Decline in Bulk Billing: explanations and implications
provides further analysis of the interaction between the number of
GPs and the rate of bulk billing, and canvasses some of the other
explanations for the recent decline in bulk
billing.(11)
Whichever of these views is more accurate, the
Commonwealth Government is limited in the ways it can go about
addressing the bulk-billing problem. One of the characteristics of
the Australian Health System is that the Commonwealth Government
cannot, under the Constitution, overtly control the fees that
doctors charge, nor can it make particular forms of billing
compulsory for some or all groups of patients. Nor, arguably, can
it force doctors to work in certain geographical areas. The 'civil
conscription' clause in the Constitution prevents a national
government from coercing or conscripting medical doctors; in lay
terms, the Government cannot force doctors to bulk
bill.(12) At best, the Government can provide incentive
measures to encourage doctors to bulk-bill, and measures that
lessen the cost impacts on patients when doctors don t bulk-bill.
This is what the Coalition Government s Medicare Plus
package of measures (and the A Fairer Medicare package
that preceded it) seeks to provide. The proposals of this Bill are
part of the Medicare Plus package.
Medicare Plus was announced on 18
November 2003, and provides $2.4 billion between now and 2006/07,
with an additional $1 billion each year thereafter. It retains or
expands on some of the measures of A Fairer Medicare, and
adds further ones.
The affordability and workforce measures in
the Medicare Plus package are:
-
For patients who are concession card holders, or members of
families in receipt of Family Tax Benefit (A), the introduction of
a concessional safety-net that will meet 80 per cent of out of
pocket medical expenses over $500 per individual or family in a
calendar year.
-
For general patients and families, the introduction of an
extended general safety-net that will meet 80 per cent of out of
pocket medical expenses over $1000 per individual or family in a
calendar year.
-
The provision of an additional $5 incentive payment to GPs for
every concessional patient, and patient under 16 years of age
bulk-billed.
-
The provision of grants to GPs and specialists to encourage
electronic lodgement of Medicare claims via HIC Online. Patients
can then have their Medicare benefits paid directly into their bank
accounts, when the consultation takes place.
-
The provision of funding to improve broadband internet access
for GPs in rural and remote areas.
-
The provision
of further funding to assist GPs assess their current business
practices and practice scheduling.
-
For practices in urban areas of workforce shortage, the
provision of grants for the employment of 457 additional full-time
practice nurses.
-
In order to
free up GP time, the creation of two new Medicare Benefits Schedule
(MBS) items for specified services provided by a practice nurse
without a GP being present.
-
The funding of an additional 150 GP training places each year
for outer-metropolitan and rural areas, and the funding of 280
short-term placements for graduate doctors in practices in outer
metropolitan, rural and remote areas.
-
The development of an international recruitment strategy to
coordinate current state and territory arrangements for recruiting
overseas trained doctors.
-
For procedural
GPs in rural and remote areas, the provision of financial support
to attend up-skilling courses.
-
For GPs
and specialists no longer practising medicine, the provision of
refresher training courses and other support to encourage their
return to the medical workforce.
-
Funding of an
additional 234 rural bonded medical school places, with up to three
years of post-graduate vocational training undertaken in rural
areas to count toward the six year bonding period that applies to
these places.
The safety-net measures, which are the
components of the MedicarePlus package contained in this
Bill, are discussed below.
There has always been a safety net arrangement
relating to patient-billed services with Medicare. This safety net
arrangement, which applies in the same manner for all patients, is
defined in terms of gap amounts paid for medical services. The gap
amount paid for a service is the difference between the Medicare
rebate for that service and its Medicare scheduled fee. The gap
amount for a service is not always equal to the total amount that
the patient may pay out-of-pocket for the service. Doctors and
specialists can, and do, charge patients more than the Medicare
scheduled fee. In such cases, the patient will have to pay the gap
amount, and the remainder of the fee charged. Under the existing
safety net, when the gap amounts that a patient has paid within a
calendar year reach $328 (the safety net threshold), Medicare will
pay 100 per cent of the gap amount that the patient is charged for
any subsequent medical services in that year. The same thresholds
and safety net coverage apply to families, as to individuals.
It has been estimated that an average of 43,
404 people per year reached the existing safety net threshold
between 1998 and 2002, and 154, 680 different people reached it at
some time in that five year period.(13) The total
safety-net benefits Medicare paid has risen from nearly $8 million
in 2000, to nearly $8.8 million in 2002.(14) The
existing safety net costs the Health Insurance Commission $6.30 per
service to manage and administer. This compares with an average
management cost of $1.43 per service for all services in
2002/03.(15)
The Bill leaves the existing safety-net
arrangement in place, and proposes the addition of two new safety
net arrangements.(16)
The establishment of an extended general
safety net is intended to provide an additional safeguard against
patients facing high out-of-pocket expenses as a result of doctors
charging more than the Medicare scheduled fee for services. Under
the proposed arrangement, once a patient s cumulative out of pocket
costs for medical services in a calendar year exceeds $1000,
Medicare would pay 80 percent of the patient s out-of pocket-costs
for any subsequent medical service in that year. Unlike the
existing arrangement, the proposed safety net includes amounts the
doctor charges above the scheduled fee, as well as the gap amount.
In other words, it includes the difference between the Medicare
rebate for the service and the fee that the doctor charges for the
service. The same thresholds and safety net coverage apply to
families, as to individuals.
A similar safety net arrangement will apply
for concession card holders and families receiving Family Tax
Benefit A (FTB (A)),(17) but with a lower safety-net
threshold amount of $500 per calendar year in recognition of the
generally lower capacity of these groups to pay out of pocket
medical expenses. Under the safety-net arrangements, benefits
covering 80% of the out-of-pocket costs for subsequent services
will be paid to families and individuals who have concessional
beneficiary status, or are registered members of a family in
receipt of Family Tax Benefit (A). The relevant concession cards
and income limits are indicated in Figure 5.
Figure 5
|
CARD
|
INCOME
LIMIT
|
|
Health
Care Card
(eg.,
people on Newstart, Youth Allowance, Parenting Payment)
|
$17, 472 pa
(single)
$29, 068 pa
(couples)
$30, 836 pa
(single/couple with one
child)
+ $1768 pa
(for each extra child)
|
|
Health
Care Card (through FTB (A))
|
$31,755 pa
(families on full rate Family Tax
Benefit Part A)
|
|
Pensioner Concession Card
(Age
pensioners, Disability support pensioners)
|
$32, 929 pa
(single)
$33, 569 pa
(single with one child)
$55, 029 pa
(couples)
+ $640 pa
(for each extra child)
|
|
Commonwealth Seniors Health Card
(Self
Funded retirees)
|
$50, 000 pa
(single)
$80, 000 pa
(couples)
$100, 000 pa
(couple if separated by illness,
care or gaol)
|
The Department of Health and Ageing has
estimated that approximately 200, 000 families and individuals each
year would access safety net benefits under the proposed
arrangements. Just over 80 percent of these (165,000) would be
concessional beneficiaries, and around 15 or 20 percent (35, 000)
would be general beneficiaries.(18) The proposed safety
net measures are estimated to cost $266.3 million over four years,
with around $15 million of this being devoted to the costs of
managing and administering the safety net.(19)
Schedule 1 amends the Health Insurance Act
1973 (the Act) to establish the new safety-nets for expenses
incurred in a calendar year for out-of-hospital Medicare
services.
Items 1 to 29 make amendments to Part II of
the Act, which provides for the payment of Medicare benefits.
Item 30 provides for the date of application
of the extended general safety‑net.
Item 1: Subsection 8(1A)
Item 1 inserts a definition for
concessional person in section 8 of the
Act. This definition is based on the definition for concessional
beneficiary for the purposes of the Pharmaceutical Benefits Scheme,
as set out in Part VII of the National Health Act 1953.
This will mean that those people who are eligible for concessions
under the Pharmaceutical Benefits Scheme will also be eligible for
the new concessional safety‑net.
A person, who, at any time in a calendar year,
becomes a concessional beneficiary under the Pharmaceutical
Benefits Scheme, will also become eligible for additional benefits
under the Medicare concessional safety-net for that year.
Item 2: Subsection 8(1A)
Item 2 provides for the threshold amount for
the concessional safety-net. The threshold amount will be set at
$500 and will be indexed annually under section 10A.
Item 3: Subsection 8(1A)
Item 3 provides for the threshold amount for
the extended general safety-net. The threshold amount will be set
at $1000 and will be indexed annually under section 10A.
Item 4: Subsection 8(1A)
Item 4 defines a Family Tax Benefit (A)
(FTB(A)) family for the purpose of the Medicare FTB(A) safety-net
as a family in receipt of family tax benefit under sections 23 or
24 of the A New Tax System (Family Assistance)(Administration)
Act 1999.
Item 5: Subsection 8(1A)
Item 5 provides for the threshold amount for
the FTB(A) safety-net. The threshold amount will be set at $500 and
will be indexed annually under section 10A.
Item 6: Subsection 8(1A)
Item 6 makes a minor amendment to the
definition of patient contribution in subsection 8(1A) to exclude
payments made in respect of a safety-net from the patient
contribution.
Item 7: Subsection 8(1A)
Item 7 adds a note for the reader pointing out
that the safety‑net amount is indexed under section 10A.
Item 8: Section 9
The effect of item 8 is to recognise that the
calculation of Medicare benefits for the purposes of the new
safety‑nets will be in accordance with the relevant
safety-net provisions.
Items 9, 10, 11, 12, 13 and 14:
Section 10AB
Items 9 to 14 make minor consequential
amendments to include references in section 10AB to the safety-nets
established in new sections 10ACA and 10ADA (being introduced by
items 17 and 20 respectively).
Item 15: After subsection
10AC(2)
It will be possible for a family to qualify
for the existing safety-net in section 10AC and/or the new
safety-nets to be established under new section 10ACA. There is no
requirement to qualify for one safety-net before the other. Item 15
amends the existing safety-net for families in section 10AC to deal
with the scenario where a family qualifies for any of the new
safety-nets before the existing safety‑net.
Item 15 inserts new subsection 10AC(2A) to
provide for the calculation of the patient contribution for the
existing safety-net to include the relevant gap after a payment is
made under one of the new extended safety-nets. This amount is the
amount that the patient is actually out-of-pocket after receipt of
a benefit paid in accordance with one of the new safety-nets, up to
the amount of the gap between the rebate and the schedule fee.
Item 16: Paragraph
10AC(6)(a)
Item 16 amends paragraph 10AC(6)(a) to include
a reference to take account of the new subsection 20(2A) proposed
by item 26.
Item 17: After subsection
10AC
10ACA Extended safety-net
families
Item 17 inserts new section 10ACA to establish
the new safety-net for families. New subsection 10ACA(1)
establishes some new definitions for the purposes of the extended
safety-net for families, including relevant services,
being out-of-hospital medical services attracting a Medicare
benefit. In-hospital services are not covered.
New subsection 10ACA(2) provides that where a
family qualifies for a new safety‑net, Medicare benefits will
be increased by 80% of the out-of-pocket expense for the claim.
New subsection 10ACA(3) defines an
out-of-pocket expense for the purposes of the extended
safety-net.
New subsection 10ACA(4) sets out the
circumstances which must apply for the extended safety-net to be
accessed. These include that the:
-
service was rendered to the claimant or a member of a registered
family unit
-
expense was incurred in the calendar year
-
claimant has
paid at least 20% of the out-of-pocket cost
-
Health Insurance Commission has accepted the claim, and
-
concessional safety‑net, the FTB(A) safety‑net or
the extended general safety‑net applies to the claim.
New subsection 10ACA(5) provides that a
safety-net will apply to a claim when that claim and all relevant
prior claims exceed the applicable safety-net amount.
New subsection 10ACA(6) defines a relevant
prior claim.
New subsection 10ACA(7) deals with how a
benefit under a safety-net will be calculated when a portion of a
claim enables a person to be eligible for a safety‑net.
Benefits under a safety-net will only be payable on the portion of
the claim by which the patient s out-of-pocket expenses exceed the
applicable safety-net threshold.
New subsection 10ACA(8) provides that a
safety-net benefit becomes payable only after a family becomes
registered. However, expenses incurred by the family before
registration will be taken into account in calculating whether the
family is eligible for safety-net benefits in that calendar
year.
New subsection 10ACA(9) provides that a person
who is paid a Medicare benefit by means of a pay doctor via
claimant cheque is deemed to have paid that portion of the medical
expense as represented by the amount of the pay doctor via claimant
cheque.
New subsection 10ACA(10) provides that the
question of when the medical expenses are incurred is determined
under the regulations.
Item 18: After subsection
10AD(3)
This item adds an identical provision to the
existing safety-net for individuals in section 10AD to the
provision added to 10AC by item 15.
Item 19: Paragraph
10AD(4)(a)
Item 19 amends paragraph 10AD(4)(a) to include
a reference to take account of the new subsection 20(2A) proposed
by item 26.
Item 20: After section
10AD
10ADA Extended safety-net -
individuals
This item inserts a new section 10ADA into the
Act. New section 10ADA is the equivalent of the new section 10ACA
introduced by item 17, except that it applies to individuals.
Items 21 and 22: Section
10AE
Items 21 and 22 make minor consequential
amendments to include references in section 10AE to the extended
safety-net established in new section 10ACA (being introduced by
item 17).
Item 23: Subsection
10A(1)
Item 23 inserts a new paragraph 10A(1)(d).
This amendment provides for the indexation of the concessional
safety-net amount, the FTB(A) safety-net amount and the extended
general safety‑net amount to be indexed on a calender year
basis in the same way as the existing safety-net. The first
indexation for these safety-net amounts is set to occur in January
2005.
Item 24: Subsection
10A(2)
Item 24 provides for the indexation day and
the reference quarter for the concessional safety‑net amount,
the FTB(A) safety-net amount and the extended general safety-net
amount by their inclusion in the CPI Indexation table in subsection
10A(2).
Item 25: Subsection
20(1A)
Item 25 amends subsection 20(1A) by including
a reference to new subsection 20(2A) being introduced by Item
26.
Item 26 inserts new subsection 20(2A). New
subsection 20(2A) will provide that where a claim for a
safety‑net benefit is only partly paid, the benefit for the
unpaid part of the account can only be paid by means of a cheque
drawn in favour of the doctor, and that the claimant may also be
paid part of the benefit if the full benefit is not paid to the
doctor.
Items 27, 28 and 29
Items 27, 28 and 29 amend paragraphs 20(3)(a),
20(4)(a) and 20(4)(b) respectively, to include references to new
subsection 20(2A), inserted by Item 26.
Item 30: Application
Subitem 30(1) provides that the Minister must,
within six months of Royal Assent publish a notice specifying the
date of commencement of the new extended safety‑net, which
must itself be within six months of Royal Assent. This will enable
the Minister to set the commencement date for an earlier time if
the systems required to administer the extended safety-net are in
place earlier than expected.
Subitem 30(2) specifies that if the Minister
does not publish a notice, the new extended safety ‑net
commencement day is taken to commence on the day after the end of
the six months of the date of Royal Assent.
Subitem 30(3) specifies these amendments apply
to expenses incurred after the commencement date for the extended
safety‑net. Expenses incurred before the commencement date
may be taken into account in determining whether a safety‑net
applies, ie in calculating whether the applicable safety‑net
out-of-pocket amount ($500 or $1000) has been reached.
Three issues have become prominent in
the public debate about the proposed safety net changes: (i)
whether safety net coverage of uncapped out of pocket costs will
lead to increased doctors fees, or over-accessing of doctors by
patients; (ii) whether the safety net thresholds are set at
appropriate levels; and (iii) whether there should be a separate
concessional safety net. The following comments briefly address
these issues.
Will the proposed safety nets provide an
incentive, or at least make it easier, for doctors to charge higher
fees to patients once they reach the safety net threshold, because
Medicare, rather than patients, will pay most of the doctors fees?
The likelihood of this is unclear. Doctors may not always know when
a patient has reached the threshold, particularly when the costs
that contribute to the threshold may come from a range of GP,
specialist and diagnostic services delivered by different
practitioners. However, it is worth noting that GPs do play an
important role in managing chronic disease and are an important
source of referrals to specialists. Consequently, it is likely that
a GP, providing care to a patient with a chronic disease, will be
aware of their patients' use of the health system and other
Medicare services. Indeed, enhancing the role of GPs in managing
chronic disease has been a focus of other programs instigated by
the current government. Nonetheless, testimony provided to the
Senate Select Committee on Medicare indicates that the Health
Insurance Commission has the information that would enable them to
detect variations in doctors fee levels for patients before and
after they reach the safety net threshold.(21) To a
minor extent also, the remaining 20 per cent of the fee that the
patient must pay might contribute to some downward pressure on the
fees the doctor charges.
Some of the debate surrounding the
proposed safety nets has centred on what the appropriate level of
annual out of pocket costs should be, for patients to qualify for
safety net coverage.(22) However, there has been little
discussion around the factors and considerations that might be
relevant to setting those levels. The Department of Health and
Ageing has stated that the $1000 threshold amount in the previously
proposed private insurance safety net of A Fairer Medicare
was chosen largely as a trade-off between costs and
benefits.(23) Clearly, though, the point of a safety net
is to protect against patients being faced with excessive or
unaffordable medical costs. Little has been said, however, about
what constitutes excessive costs, or what makes medical costs up to
a certain point ones that the patient should bear, but
costs after that point ones which should be borne through state
based insurance. Without some criteria or account of these things
it is not clear how the issue of where to set the safety net
thresholds can be systematically debated or credibly
resolved.
The existing Medicare safety net applies
to individuals and families regardless of their income or
concessional status. Proposing a separate concessional safety net
with a lower threshold than for general patients presumably
reflects a view that concessional patients are at a higher risk of
being faced with unaffordable medical costs than general patients.
There are three possible ways in which this risk might be
higher:
-
concessional patients are more likely than
general patients to access services which are not bulk billed (and
which, consequently, involve an out of pocket expense),
or
-
concessional patients access a higher number of medical services
than general patients, and even if they access patient billed
services at the same rate as general patients, they will
access more of them, or
-
the same
level of out of pocket costs will be less affordable for
concessional patients than for non concessional
patients.
As was indicated earlier, there is very
little Medicare data available that is specific to concession card
holders. However, the data that there is does not always support
the view that concessional patients are at a higher risk of
unaffordable medical costs than general patients in the three ways
above.
Over 70 per cent of full-time equivalent
GPs bulk-billed at least 80 per cent of their services for
concessional patients in 2002. Over one-third of those doctors
bulk-billed all of their services for concessional
patients.(24) There is evidence also that GP bulk
billing rates do not vary greatly between different income groups.
Figure 6 below indicates the low level of variation for
2001/02.(25)
Figure
6
An independent analysis of the
relationship between bulk billing rates and income levels does
suggest a weak correlation between the two, but suggest that this
is just as likely explained by regional differences.(26)
It was noted above also that the GP bulk billing rates for
concessional patients in 2001 and 2002 were 86.4 per cent and 80.7
per cent respectively. This compares with 75.7 per cent and 71.5
per cent for the whole population for those respective
years.(27)
There is little data on the number of
services that concessional patients access compared to
non-concessional patients, particularly over time. However, figures
for patients over 65 years compared to those under that age range
might provide a rough picture of relative usage. According to
Health Department Medicare statistics, over 65s accessed, on
average, 25.3% of all the Medicare medical services each year
between 1996/97 and 2002/03. It is true that the number of services
accessed by over 65s has increased at a higher annual rate than
that for under 65s in that six year period (an average annual rate
of 4.3% compared to 1% respectively). (28)But, it still
remains that only around a quarter of all medical services are
accessed by that older age group. Bearing in mind that these
figures only give a rough idea of concessional usage, they do not
support the contention that concessional patients access a higher
total number Medicare services than non-concessional.
The income limits on eligibility for
most concession cards do suggest that the same medical expense is
likely to constitute a higher proportion of the income of
concessional patients than noon-concessional patients. However, it
is arguable that this would not necessarily be true for holders of
Commonwealth Seniors Health Cards, where the income limit for
singles is $50, 000. There is also the related question as to
whether concessional patients are on average charged more or less
for medical services than general patients. Information from the
Department of Health and Ageing indicates that the average payments
per GP service made by patients over 65 years have been
consistently less than the rest of the population between 1996/97
and 2002/03 (to March). Moreover, even though the average payments
paid by both cohorts has increased over that period, the increase
has been less for over 65s. (33.8 per cent increase for over 65
years, and 47 per cent increase for the rest of the
population).(29)
These observations are by no means
conclusive, and the data available is very limited. However, the
available evidence does suggest that concessional patients may not
be at as high a risk of unaffordable medical costs as the
establishment of a separate and more protective safety-net
arrangement might suggest. At the very least, there seems to be
little in the way of publicly available data to support the view
that a concessional safety net is strongly warranted.
-
Through the Australian Health Care Agreements
with the States and Territories.
-
Amanda Biggs, 'Medicare Background Brief', Parliamentary
Library E-Brief, at http://www.aph.gov.au/library/intguide/SP/Medicare.htm.
-
A brief discussion of the universality of Medicare can be found
in the Parliamentary Library Publication:
Is Medicare Universal? Amanda Elliot, Research Note
No. 37 2002-03.
-
Medicare Statistics, September Quarter 2003.
-
Senate Community Affairs Legislation Committee, Examination of
Budget Estimates, Additional Information Received, Vol. 4, November
2003, p. 2. Metropolitan consists of RRMA 1 & 2 classified
areas, and rural consists of RRMAs 3 7.
-
Senate Community Affairs Legislation Committee Examination of
Budget Estimates 2003-04, Additional Information Received, Vol. 4,
November 2003, p. 86.
-
Medicare Statistics, September Quarter 2003.
-
Department of Health and Ageing, Supplementary Submission to the
Select Committee on Medicare, December 2003, p. 4.
-
Kerryn Phelps, GP Bulk-billing rates dive again , AMA Press
Release, 30 August 2002.
-
Department of Health and Ageing, Supplementary Submission to the
Senate Select Committee on Medicare, December 2003, p. 3.
-
Amanda Elliot, 'Decline in Bulk Billing: Explanations and
Implications', Current Issues Brief No. 3 2001-02.
-
The 'civil conscription' clause is contained in s. 51(xxiiiA) of
the Constitution.
-
Department of Health and Ageing, Supplementary Submission to the
Senate Select Committee on Medicare, December 2003, p. 18.
-
Senate Select Committee on Medicare Hansard 28/08/03,
p. 86
-
Estimate supplied by the Health Insurance Commission, Tuesday
November 25, 2003.
-
There is also another safety net arrangement that operates
through the tax system. Section 159P of the Income Tax
Assessment Act 1936 provides for a 20% rebate on medical
expenses incurred in a financial year over $1500. This, however, is
only payable against income that is taxable for the financial
year.
-
The purpose of FTB part A is to help families with the cost of
raising children. To be eligible for FTB part A an individual must
have a dependent child under 21 or a dependent full-time student
aged 21 to 24, be an Australian resident and meet the income test.
Over 1.8 million families with over 3.4 million children are
currently receiving the payment on a fortnightly basis. Around
100,000 people claim FTB through the tax system
-
Senate Select Committee on Medicare Hansard 20/01/04,
p. 57
-
Department of Health and Ageing, Supplementary Submission to the
Senate Select Committee on Medicare, December 2003, p. 21.
-
This section is based on the Explanatory Memorandum.
-
Senate Select Committee on Medicare, 2003, Medicare
healthcare or welfare?, p. 90. The relevant information is not
currently used for this checking purpose, however.
-
This has been reported as one of the sticking points between the
Democrats and Coalition Government in negotiating passage of this
Bill through the Senate. See Democrats stall on Abbott s Medicare
changes . The Age, 4 December 2003.
-
Mr Davies, Department of Health and Ageing, Proof Committee
Hansard, Canberra 28 August 2003, p. 89
-
Department of Health and Ageing, Supplementary Submission to the
Senate Select Committee on Medicare, December 2003, p. 12.
-
Department of Health and Ageing, Supplementary Submission to the
Senate Select Committee on Medicare, December 2003, p. 4.
-
Ian McAuley, 2003, Bulk billing by Income/Electorate ,
submission to the Senate Select Committee on Medicare, January
2004.
-
Medicare Statistics, September Quarter 2003.
-
Medicare Statistics, September Quarter 2003. Table D1.
-
Senate Community Affairs Legislation Committee, Examination of
Budget Estimates, Additional Information Received, Vol. 4, November
2003, p. 86.
Maurice Rickard
13 February 2004
Bills Digest Service
Information and Research Services
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