Out-of-pocket expenditure, need, utilisation, and private health insurance in the Australian healthcare system

Despite widespread public service provision, public funding, and private health insurance (PHI), 20% of all healthcare expenditure across the OECD is covered by out-of-pocket expenditure (OOPE). This creates an equity concern for the increasing number of individuals with chronic conditions and greater need, particularly if higher need coincides with lower income. Theoretically, individuals may mitigate OOPE risk by purchasing PHI, replacing variable OOPE with fixed expenditure on premiums. Furthermore, if PHI premiums are not risk-rated, PHI may redistribute some of the financial burden from less healthy PHI holders that have greater need to healthier PHI holders that have less need. We investigate if the burden of OOPE for individuals with greater need increases less strongly for individuals with PHI in the Australian healthcare system. The Australian healthcare system provides public health insurance with full, partial, or limited coverage, depending on the healthcare service used, and no risk rating of PHI premiums. Using data from the Household, Income and Labour Dynamics in Australia survey we find that individuals with PHI spend a greater share of their disposable income on OOPE and that the difference in OOPE share between PHI and non-PHI holders increases with greater need and utilisation, contrary to the prediction that PHI may mitigate OOPE. We also show that OOPE is a greater concern for poorer individuals for whom the difference in OOPE by PHI is the greatest.

An ethics analysis of the rationale for publicly funded plastic surgery

Background

Healthcare systems are increasingly struggling with resource constraints, given demographic changes, technological development, and citizen expectations. The aim of this article is to normatively analyze different suggestions regarding how publicly financed plastic surgery should be delineated in order to identify a well-considered, normative rationale. The scope of the article is to discuss general principles and not define specific conditions or domains of plastic surgery that should be treated within the publicly financed system.

Methods

This analysis uses a reflective equilibrium approach, according to which considered normative judgements in one area should be logically and argumentatively coherent with considered normative judgements and background theories at large within a system.

Results and conclusions

In exploring functional versus non-function conditions, we argue that it is difficult to find a principled reason for an absolute priority of functional conditions over non-functional conditions. Nevertheless, functional conditions are relatively easier to establish objectively, and surgical intervention has a clear causal effect on treating a functional condition.

Considering non-functional conditions that require plastic surgery [i.e., those related to appearance or symptomatic conditions (not affecting function)], we argue that the patient needs to experience some degree of suffering (and not only a preference for plastic surgery), which must be ‘validated’ in some form by the healthcare system.

This validation is required for both functional and non-functional conditions. Functional conditions are validated by distinguishing between statistically normal and abnormal functioning. Similarly, for non-functional conditions, statistical normality represents a potential method for distinguishing between what should and should not be publicly funded. However, we acknowledge that such a concept requires further development.

Do healthcare needs-based population segments predict outcomes among the elderly? Findings from a prospective cohort study in an urbanized low-income community

Background

A rapidly ageing population with increasing prevalence of chronic disease presents policymakers the urgent task of tailoring healthcare services to optimally meet changing needs. While healthcare needs-based segmentation is a promising approach to efficiently assessing and responding to healthcare needs at the population level, it is not clear how available schemes perform in the context of community-based surveys administered by non-medically trained personnel. The aim of this prospective cohort, community setting study is to evaluate 4 segmentation schemes in terms of practicality and predictive validity for future health outcomes and service utilization.

Methods

A cohort was identified from a cross-sectional health and social characteristics survey of Singapore public rental housing residents aged 60 years and above. Baseline survey data was used to assign individuals into segments as defined by 4 predefined population segmentation schemes developed in Singapore, Delaware, Lombardy and North-West London. From electronic data records, mortality, hospital admissions, emergency department visits, and specialist outpatient clinic visits were assessed for 180 days after baseline segment assignment and compared to segment membership for each segmentation scheme.

Results

Of 1324 residents contacted, 928 agreed to participate in the survey (70% response). All subjects could be assigned an exclusive segment for each segmentation scheme. Individuals in more severe segments tended to have lower quality of life as assessed by the EQ-5D Index for health utility. All population segmentation schemes were observed to exhibit an ability to differentiate different levels of mortality and healthcare utilization.

Conclusions

It is practical to assign individuals to healthcare needs-based population segments through community surveys by non-medically trained personnel. The resulting segments for all 4 schemes evaluated in this way have an ability to predict health outcomes and utilization over the medium term (180 days), with significant overlap for some segments. Healthcare needs-based segmentation schemes which are designed to guide action hold particular promise for promoting efficient allocation of services to meet the needs of salient population groups. Further evaluation is needed to determine if these schemes also predict responsiveness to interventions to meet needs implied by segment membership.

Population characteristics and geographic coverage of primary care facilities

BACKGROUND

The location of General Practitioner (GP) facilities is an important aspect in the design of healthcare systems to ensure they are accessible by populations with healthcare needs. A key consideration in the facility location decision involves matching the population need for the services with the supply of healthcare resources. The literature points to several factors which may be important in the decision making process, such as deprivation, transportation, rurality, and population age.

METHODS

This study uses two approaches to examine the factors associated with GP accessibility in Northern Ireland. The first uses multinomial regression to examine the factors associated with GP coverage, measured as the proportion of people who live within 1.5 km road network distance from the nearest GP practice. The second focuses on the factors associated with the average travel distance to the nearest GP practice, again measured using network distance. The empirical research is carried out using population and geospatial data from Northern Ireland, across 890 Super Output Areas and 343 GP practices.

RESULTS

In 19% of Super Output Areas, all of the population live within 1.5 km of a GP practice, whilst in 24% none of the population live within 1.5 km. The regression results show that there are higher levels of population coverage in more deprived areas, smaller areas, and areas that have more elderly populations. Similarly, the average travel distance is related to deprivation, population age, and area size.

CONCLUSIONS

The results indicate that GP practices are located in areas with higher levels of service need, but also that care needs to be taken to ensure rural populations have sufficient access to services, whether delivered through GP practices or through alternative services where GP practices are less accessible. The methodology and results should be considered by policy makers and healthcare managers when making decisions about GP facility location and service provision.