40 years on: How can Medicare meet the changing health needs of Australians in the future?
As Australia celebrates 40 years since Medicare first revolutionised access to medical services, pharmaceuticals and hospital care; researchers from the Centre of the Business and Economics of Health (CBEH) reflect on how public health services and technologies need to evolve to meet the future health needs of Australians.
Improving patient access to new treatments
Professor Haitham Tuffaha, Interim Director, Centre for Business and Economics of Health
The Australian Government funds new medicines and health services through subsidy schemes, including the Pharmaceutical Benefits Scheme (PBS) and the Medicare Benefits Schedule (MBS). Funding decisions are informed by a well-established health technology assessment (HTA) process that evaluates health interventions for quality, safety, efficacy, and cost-effectiveness.
With the increasing number of new health interventions entering the Australian market, evaluating novel technologies, such as cell and gene therapies, grows more complex. As a result, the current HTA processes and methods need to be improved to ensure that Australians can access safe, effective, and value-based health interventions in a timely and equitable manner.
A review of Australia’s HTA approach is currently underway to identify what works well and what needs improvement to meet future challenges. For this review to be successful, it’s essential to develop a fit-for-purpose, efficient, and flexible framework that evaluates new health interventions. Ideally, this framework should provide timely access to innovative treatments while ensuring value-based healthcare.
HTA processes could be streamlined to potentially reduce the burden on Australian agencies through international collaboration for joint assessments. Additionally, a balanced approach to HTA could be implemented, where different levels of scrutiny and resources are applied based on the complexity and risk of treatments. Low-risk submissions might benefit from a simpler evaluation process compared to complex and high-risk treatments.
Horizon scanning of new health interventions will help decision-makers prepare for potential challenges and complexities, such as evidence requirements. To address uncertainties in the evidence available on new technologies, more funding from the National Health and Medical Research Council (NHMRC) and Medical Research Future Fund (MRFF) could be directed toward research that directly informs HTA decisions. Furthermore, enhancing the use of flexible funding arrangements, such as Managed Access Programs, could allow provisional funding for promising treatments while additional data is collected.
Reimagining multidisciplinary teams in primary health care
Dr Jean Spinks, Health Economist
Like many governments worldwide, the Australian Government aims to incentivise multidisciplinary teams to work together to improve population health outcomes. Team based care occurs when people’s needs are met by a variety of health professionals in a coordinated way. Although the concept is generally well accepted, the operationalisation of this aim within a dynamic health care system isn’t easy. Arguably, the (over)reliance on Medicare fee-for-service structures is part of the problem. Health practitioners are incentivised to be task-focused rather than undertake prevention or a collaborative model of healthcare.
Medication safety is a good example of why ‘people slip through the cracks’ as no single practitioner is solely responsible for all elements of prescribing, dispensing and monitoring medication use. Medication problems can occur due to underuse, overuse or inappropriate use. However, there is no routine oversight of the rates of such problems, their consequences, or the development of cost-effective interventions to prevent and resolve them.
Digital solutions can assist in identifying targeted interventions, but are insufficient on their own without agreement on:
- who might lead interventions
- where the workforce is physically based
- how medication problems might be resolved
- how such activities are funded
- how routine measurement of outcomes occurs.
Allied health practitioners, including pharmacists, aren’t often co-located with general practices. This creates additional workflow barriers which need to be navigated.
These are systems-based problems that require system-based solutions. Elements of person-centred care, digital health, health workforce training and health care financing are all relevant in finding a solution. Consumer and health practitioner preferences must also be considered. Such case studies are necessary and powerful as they highlight the range of issues to be simultaneously addressed and meet the aim of, for example, ‘safe medication use’.
Most importantly, cultural change is required across health practitioner groups to move beyond the current ‘turf wars’ and shift the focus back onto population health outcomes. Changes to Medicare funding are required to support the Australian Government in achieving their multidisciplinary care goal.
Optimising the scope of practice for our health workforce
Professor Lisa Nissen, Implementation Scientist
The health workforce is one of our greatest health system resources. However, workforce planning has frequently focused on population density and the subsequent distribution of specific health professions to ensure universal access to and coverage of health services. For example, the number of doctors or nurses required in relation to the amount of people in a particular place. This current planning method encourages a siloed approach to addressing patient and service needs, which in turn drives service models, funding, and infrastructure planning.
Generally, there’s been limited attention placed on identifying the right composition and skill mix of the health workforce based on the needs of the population, or the best funding support for those teams. By including a scope of practice lens in our workforce planning, we have an opportunity to develop an interdisciplinary view of patient care and agreement on the essential services. Rather than focusing on professionals, this approach would highlight the skills and capabilities required to deliver optimal health outcomes for patients.
This refined approach could also be useful in models of health like primary care that present opportunities to enhance capability in the health system by supporting areas with overlapping scopes of practice. Australia’s Primary Health Care 10-Year Plan 2022-2032 outlines a need to shift primary care to a patient-centred system focused on wellbeing instead of illness. The plan endorses a value-based view of the primary health care system rather than a volume-based one, with coordinated and multidisciplinary care teams instead of multiple independent and sometimes competing providers. This view allows further optimisation of care models where individual practitioners can combine their scopes of practice and share their skills and capabilities across the system and team.
Optimising the various scopes of practice for health professionals within the current health system is complex. These complexities highlight the importance in providing suitable incentive structures, training and education, and interprofessional collaborative teams. As such, advocacy and leadership are critical in supporting any meaningful system change.
Future impact of private and public health insurance
Professor Luke Connelly, Health Economics
Throughout the 40 years Medicare has been in place, it’s maintained popular support across the political spectrum as a universal public insurance scheme that offers both public and private providers. As a result, attempts to change the system have been met with staunch opposition from the public and Medicare’s fundamental characteristics are unlikely to change over the next 20 years. Private health insurance (PHI) also plays an important role in supplementing the public and private sector functions of Medicare and is likely to remain important as roughly 45% of Australians still buy PHI cover for private hospital care.
The viability of PHI was a major challenge Australia had faced up until the mid-1990s. What looked like a potential crisis – with some commentators even predicting a complete collapse of the industry – has since been averted through a series of “carrot-and-stick” measures. These measures were put in place to incentivise lower-income households to purchase PHI while penalising higher-income earners who don’t buy PHI through substantial tax penalties. As a result, it now makes financial sense for many mid-to-high-income households to buy PHI. Even if they anticipate paying more in premiums than they’ll receive in benefits, there are generally policies that will qualify them for an exemption to the Medicare Levy Surcharge (MLS) which costs less than the additional tax.
The headwinds facing PHI now are different. Many private hospitals have found it difficult to cover their costs in the current market, and those costs will likely continue to increase at a rate greater than overall inflation. That means insurance premiums will need to increase in order to cover the benefits paid. This is likely to put greater pressure on insurers as the public wearies of constant, and often substantial, annual premium increases. To maintain the current level of private health coverage, governments are likely to increase the MLS to discourage some middle-income earners from dropping their coverage entirely.