Healthcare journeys – The end of the line

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By Lucy Cheetham – APHA director of policy and research

Dr Norman Swan’s feature on ABC’s Four Corners program last week was grim viewing.

‘Wasted’ presented a powerful perspective on some of the challenges facing the Australian health sector and the consumers it aims to care for.

We were told about how much of the money we pay for health services turns to waste due to practices that can lead to overdiagnosis and sometimes ineffective treatments.

Australia’s health system has long been unwieldy and Dr Swan’s report depicted it as being akin to a “commuter network, but unimaginably more complex”.

In the report, Dr Swan effectively used a railway analogy to reflect both the complexity of the health sector and the speed with which consumers can find themselves caught up in a system in which they have no control – that is when they are not left waiting on the platform.

But there were some significant omissions in Dr Swan’s report; his perspective powerful but partial. These omissions are important if we are to frame effective policy responses based on realistic expectations.

Let’s take the railway analogy a few steps further. Consumers navigating the health system often run into problems on their journey in the same way passengers on a train encounter delays.

Suddenly, junctions are switched and we are diverted to another line. Can we stop, get off at the next station and switch to another train?

The answer depends on a number of variables and sequences of events; it is not just the driver (doctor) who is responsible for delivering us to our desired destination.

Private health insurance is a good example. Consumers purchase private insurance for the timely access to care and the choice it gives them. Having private health cover should mean you always have more options, right? Wrong.

Private health insurance can open up care options, but it can also block access as well.

Treatment for heart disease is one such example. Cardiovascular stenting, highlighted in Dr Swan’s report, is a minimally invasive procedure to treat heart disease.

Doctors use a stent and a balloon to push back plaque deposits inside a coronary artery. It works, but it is expensive. Before a stent is used, a flow wire can be used to determine whether a stent will be appropriate.

What Dr Swan neglected to mention is that health funds have consistently refused to fund flow wires despite the extensive evidence of the technology’s economic and clinical benefits.

Health funds are required by law to describe to consumers the services their products cover, but the consumer information they provide is only half the story.

The contracts health funds choose to strike, or not, with hospitals and other health services determine whether a patient’s fund will meet the cost of their treatment entirely or if they will be left with a hefty out of pocket charge.

Private health insurance may get you on the train, but there are often additional expenses once on board, especially if you find your health fund has decided not to cover that part of the journey.
For example, your health fund may have a contract with your hospital but not with the pathology service. That’s particularly bad news if you need a blood test while you are there.

Sometimes you may find that your cover ends when your journey is only half complete. A successful health outcome may depend on access to a coordinated clinical rehabilitation program, yet rehabilitation is one of the services most frequently restricted in private health insurance policies.

Failure to access rehabilitation can mean a less favourable outcome from previous treatments, or worse, a loss of quality of life and a higher likelihood of further medical intervention. In turn, the patient incurs additional expenses.

Switching to the public health system may seem like a good idea if your insurance policy doesn’t cover you in the private sector, but it’s not that straightforward.

It is not uncommon for private hospital patients to find that they cannot access government funded community palliative care because these services prioritise referrals from public hospitals. As a result, patients find themselves stranded at the end of the line.

As Dr Swan says, “if only our journey as patients in the Australian health system was as straightforward as getting on a train from A to B”.

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