Co-payments do not represent evidence based medicine or policy making

The Abbott Government has proposed a $7 co-payment for visits to general practitioners and a number of diagnostic services. In addition the co-payment for medicines may also be raised. This follows a recommendation from a National Commission of Audit that recommended a higher level of co-payment. Ostensibly the funds saved will be be invested in a Healthcare Research Fund that will in turn be used to support future health-related research. The purpose of healthcare research is essentially to gain evidence to support best practice – or what is commonly known as evidence-based medicine (EBM). So are health co-payments evidence-based?

The introduction of co-payments aims to reduce unnecessary visits to general practitioners and reduce unnecessary diagnostic testing. The problem with this approach is that it does not actually identify the extent to which unnecessary visits are a problem nor does it take into account that most individuals can’t actually identify whether their proposed visit is unnecessary nor do they have the tools to work it out. A flow on consequence is that it is individuals in lower socioeconomic strata that will choose not to attend their general practitioner regardless of whether the visit is unnecessary or for a genuine problem. In essence the introduction of co-payments reduces access to healthcare and possibly for those most in need. The Government argues that only those that really need the attention will now seek it. The naysayers say the individuals will just attend emergency departments.

If co-payments reduce access to care then what will be the effect? Worse health outcomes. This is graphically illustrated by the alternative scenario described by Sommers et al in Annals of Internal Medicine (2014) http://www.ncbi.nlm.nih.gov/pubmed/24798521 . This paper describes through time series analysis the introduction of near universal health care in the state of Massachusetts in 2006. These changes are similar to the Affordable Healthcare Act a.k.a Obamacare. Following the introduction of improved access to healthcare all-cause mortality in the state fell. I doubt the all-cause mortality in Australia would rise significantly with a co-payment, in part because of the acute care sector and also because avoidance due to co-payments tends to wane quickly but it is likely to increase the burden of illness especially for patients with chronic disease.

An alternate way to look at this issue is to look at patient adherence to medications. Lack of adherence is a major contributor both to healthcare morbidity and also rising healthcare costs. Sinnott et al in PLoS One (2013) http://www.ncbi.nlm.nih.gov/pubmed/23724105 looked at factors that improved patient adherence and demonstrated co-payments to be associated with worse adherence. Similarly Viswanathan et al in Annals of Internal Medicine (2012) showed that reduction in out of pocket costs, case management and patient education improved medication adherence in chronic disease settings.

So what are the implications for the co-payment policies related to general practice visits, diagnostics and medicines? Overall the literature (and this is but a small sample) would suggest that health outcomes will be worse and consequently there will be greater health expenditure in the rush to treat the side effects of these policies.

There is no doubt that ways of paying for healthcare to ensure a sustainable system must be found but co-payments as taxation is probably not the means. Other forms of taxation are required and perhaps Governments should reflect that the message they should be sending is not so much about the elevated taxes but how and where the money will be spent.

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