Debate about the Medicare Select proposal continues.

Professor Stephen Leeder, professor of public health at the University of Sydney, argues the case against.

He writes:

“The prime minister, Mr Kevin Rudd, is conducting an extensive “direct consultation with the health sector and with communities around the nation” about the health reforms proposed by the National Health and Hospitals Reform Commission whose final report was received on June 30th this year.

As President Obama is doing in the US, Mr Rudd is taking a deep personal interest in health reform, and this is immensely encouraging.  The report of the Commission is a thoughtful, expanasive document that embraces the complexity of the health care system in its 123 recommendations, ranging from concerns about public hospitals through to the more arcane need for improvement in health literacy in Australia.

Mr Rudd has made it plain that there are constraints upon reform, not least the fiscal limits of the global financial crisis.  “Whatever options we adopt,” Mr Rudd has declared in stentorian voice, “we will be adopting them within the context of fundamental fiscal disciplines.”  Hmmmm.

An additional constraint is the sheer political and bureaucratic complexity of the health system, a kind of secular equivalent of the Vatican where states (bishops and cardinals) all have distinctive views and vested interests.  The Council of Australian Governments is the forum within which much of this political complexity is played out, and a special meeting of this agency is to be held later this year to consider health and hospital reforms.

Already changes in the way states receive money from the Commonwealth (much less earmarked funding, much more ‘do it your way and we will hold you to account) is changing the landscape.  Mr Rudd has threatened that unless things improve he will seek a mandate from the people on reform.

Against the background of Mr Rudd’s travelling consultative caravan and the 123 recommendations of the NHHRC, has emerged ONE idea and that is that perhaps we should change Medicare quite radically.

It is that we turn out attention as a moderate sized nation sprawling across the largest continent on earth to the health care systems that have been created with decades of travail and angst in two of the geographically smallest and most demographically compressed nations – the Netherlands and Israel.

Both Israel and Netherlands collect funds in one central pot, and then distribute a capitation payment to sickness funds on an individual and prospective basis. Israel adjusts its payment for age; Netherlands adjusts its payment for age, sex, region, employment status, and disability.

Under Medicare Select, which we are assured will not be like managed care, the ills of the current system will disappear.  Doctors will willingly move to the bush.  There will be no more miscarriages in hospital emergency departments.  Money, presumably a great deal of it  including $11B a year for public hospitals; $10B for the PBS, and $17M a year for the MBS will be rolled into one pool and allocated to whichever insurer you choose to arrange your care, according to a formula that takes account of your age and health risk.

Questions?  First, what is the problem Medicare Select is meant to solve?  Waiting lists, no doctors in the bush, poor mental health services?  If we are clear  – and this is where the NHHRC Report is weakest – on the definition of the needs that would drive reform, then we might be better able to assess the proposed solutions including Medicare Select.

There is a major imbalance between hospital and primary care in Australia, there is a health bureaucracy that has grown beyond the wildest imagination, there are entrenched political resistances in the medical profession and elsewhere, pantehnicons carrying chronic disease shipments are thundering down the toll way, public hospitals have been stripped and general practice struggles.  Will Medicare Select help solve these problems?

Second, is what is being proposed any better for Australians’ health, rather than better for the private sector providing health care, and if so, is that a reason to change from Medicare to Medicare Select?

Third, if you worry that current administration of Medicare is inefficient, and you would have a hard time proving that, would splitting it into three improve efficiency?

Fourth, how would competing health funds – the three or so agencies that would make up Medicare Select – be managed and by whom and with what skills?  The workforce challenge would be large.

Fifth, how would we assure equity in this setting?  Reflect for a moment on the problems of getting privatised Telstra interested in the bush.  Why should an agency (Green, Red or Blue Medicare Select) not seek to provide care only where the costs ot them are low?

Time, I think, to turn our attention to the other 122 recommendations and see what can be done.  In the words of AMA president Andrew Pesche, we should seek to fix what’s broken.  The things that are broken do not include Medicare.”

• This article was first published in Australian Doctor magazine

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