Wednesday, February 15, 2012

The Doctor Down Under

I’m back to my blog after a few months hiatus. Since I wanted to continue my examination of the Australian health care system, I was thrilled that my Canadian pal, Rosie, was able to give me an email introduction to Dr. Sue O’Brien, a general practitioner in the health care clinic for Flinders University in Adelaide, Australia. Dr. O’Brien and I were able to chat via Skype about her experiences with the Australian health care system.

I was particularly interested in her perspectives as a physician in the Land Down Under. I decided to begin at the beginning with the cost for doctors to get their training. The tremendous student debt our young US physicians rack up is part of the case they make for being paid more here than in other countries. “Is it very expensive to train to be a physician in Australia?” I asked. “Well, at the time that I trained,” Sue responded, “it was completely free, plus I had a little bit of living support, which the federal government paid for.” Wow, can’t beat that with a stick!

But, as it turns out, the system is a bit different now. Still, most medical students who are Australian citizens only have to pay 1/3 of the tuition while the government pays the other 2/3. That averages about $9,000 per year for which the student is responsible. And a student at any income level can get a government loan for the full $9,000, which they don’t have to start paying back until they are earning a certain amount of money. If for some reason they never reach that threshold of earnings, they don’t have to repay the debt.

Do young Australian physicians still feel they finish school with an oppressive amount of debt? “They do feel that. They certainly do feel that,” was Dr. O’Brien’s reply. I guess starting one’s professional career already $36,000+ in debt is somewhat daunting but it can’t quite compare to the hundreds of thousands young US physicians owe.

My mind still on money, I asked Sue how she got paid. She told me that for her general practice patients, she does bulk billing. Bulk billing means that a doctor is willing to accept just the amount that Medicare covers. So the care is free for the patient. Australian docs are not obliged to bulk bill and can charge whatever they want. But even when Sue was in other practices, before she worked at the university, she accepted bulk billing. Consequently, she has seen many patients who were particularly needy.

In my previous post, “An American in Oz”, I wrote about how the Medicare Safety Net protects Australians from high non-hospital medical costs. When I asked Sue about the Safety Net, she mentioned there is also a Pharmaceutical Benefits Safety Net, which protects Australians from high medication costs. Even before Australians incurs high medication costs, they all qualify for the government Pharmaceutical Benefits Scheme. Under this plan, general patients can get most medications for $35 or less. When patients qualify for a concession because they: make less than $25,000 per year, are a student, are seeking work, are a pensioner – they can get generic prescriptions for $5.80. If a patient uses a brand name drug when a generic exists, the patient will have to pay more.

After a general patient has spent $1363 on medications in a year, the Pharmaceutical Benefits Safety Net kicks in and the rest of their medications cost $5.80. This benefit is not means-tested. If a patient is a Concession Card holder, their medications are free after they spend $348.

The Pharmaceutical Benefits Scheme covers only medications that are on the Schedule of Pharmaceutical Benefits. Dr. O’Brien informed me that most necessary medications are covered – most life saving drugs, medications for diabetes, hypertension, cardiac disease, infections, as well as medications for pain, anti-inflammatory agents, and oral contraceptives. Drugs that are not covered include some very new drugs, often for cancer, that haven’t been evaluated and approved by the government yet. “Are you ever unable to prescribe in a way that is in the best interest of your patients?” I enquired. “Hardly ever,” Dr. O’Brien stated emphatically. “Very rarely do I feel that a person needs a medication that they won’t be able to afford and there’s no alternative.”

Continuing this line of questioning regarding restrictions on what the government will cover, I asked whether in general she felt limitations on government health care coverage ever prevented her from giving her patients the best possible care. Her response was that Medicare doesn’t usually cover ancillary care – dieticians, physical therapists, podiatrists, dentists, psychologists – except for patients with serious chronic illnesses, for example diabetes, rheumatoid arthritis, or asthma. So occasionally Sue has patients who really need those services but because they don’t qualify for special chronic illness health support they aren’t able to afford it. However she added, “It’s quite unusual for me to feel that my patient really needs something that they won’t be able to get or that they will need something that they will not be able to afford.”

Sounds pretty good, doesn’t it?

Let’s look at some statistics that reflect the relative problem of affordability in Australia, Canada, and the US. According to a Commonwealth Foundation study, the percentage of people in these countries that had medical problems but didn’t visit a doctor due to cost concerns was 13% Australia, 4% Canada, and 22% US. Among below average earners, lower income US residents were about 2½ times more likely to have a serious problem or complete inability to pay medical bills than lower income Canadians or Aussies. Even above average US earners were twice as likely as above average Australian earners to have problems paying medical bills and about 5 times more likely to have difficulties than Canadians with above average income. So while some Australians have affordability issues, it’s a far less severe problem than in the US.

Going broke in Australia due to medical debt? “It would be rare,” said Sue. “Because hospital care, everybody’s covered for hospital care in the public sector. There are no costs for that.”

What about my favorite question: waiting lists? “Would you say that patients’ medical conditions deteriorate due to the waits?” I asked Dr. O’Brien. “I think that may happen sometimes,” she answered. “If somebody needs a hip replacement, there’s an optimal time to do it. And if the person has a lot of other medical problems, if they have chronic health problems like cardiovascular disease or diabetes, then because they have to wait, and they might have to wait for a year or something like that, then their other health conditions might deteriorate. And they may not be such a good operating risk.” But on the other hand, “What I find though, is that, and I’m sure other doctors would agree with this, if it’s a serious problem, let’s say it’s a dermatological problem and the person has a terrible rash, which is difficult to diagnose. Then you [the doctor] ring up somebody in the public system, you ring up the clinic, or the referral that you send, sends it as an urgent problem. And they’re very likely to be seen quickly.”

When I asked Sue whether there was anything that bothered her about the Australian health care system she asserted, “I think it’s quite a good system!” She went on, “If I try to think of ways in which it could be improved – There could perhaps be more direct funding of doctors who are willing to work in public hospitals. It used to be the case that there was more direct government funding for that. But the government has tried to get the private system to pay for more, a bigger proportion of the health service… More direct funding for doctors who are willing to work in the public system would presumably lessen the waits for people who can’t afford to get their health care in the private system. Because that’s probably the biggest problem. Waits in the public system.”

Australia’s national health care system, while not perfect, gives residents the option of health care that costs them nothing at the point of service. Medications are available to everyone at a relatively low cost. And although affordability is an issue for some, it is on a much lesser scale than in the US. There is also a private insurance industry that gives speedier access, more covered ancillary benefits, and upgraded hospital choices. Perhaps this is a model more palatable to Americans than systems that are more strictly egalitarian.