Disparities in experiences of emergency department care for people with a mental health condition.

BACKGROUND: The aim of this study was to explore differences in experiences of care in Emergency Departments (EDs) for people with and without mental health conditions. METHODS: Secondary analyses of a survey of 15,995 patients from 82 EDs in New South Wales, Australia was conducted focusing on the most positive responses for 53 questions across nine dimensions of experiences. Logistic regression was used to compare experiences between people with and without a self-reported mental health condition, regardless of the reason for presentation. RESULTS: Most patients reported positive experiences, with 60% rating care as 'very good'. However, fewer people with mental health conditions gave 'very good' ratings (52%). Their experiences were significantly less positive for 40 of 53 questions. For overall impressions of professionals, physical comfort, and continuity dimensions, experiences for those with mental health conditions were at least eight percentage points lower than those with no condition. Differences were minimal for other questions such as experiences with facilities (e.g. clean treatment areas). CONCLUSIONS: Regardless of the reason for their visit, improvements in experiences for people with mental health conditions should focus on interactions with healthcare professionals, comfort, engagement and continuity. Improving experiences of this group can help improve their outcomes of care.

Assessing Performance in Health Care Using International Surveys: Are Patient and Clinician Perspectives Complementary or Substitutive.

BACKGROUND: Over the last decade, international surveys of patients and clinicians have been used to compare health care across countries. Findings from these surveys have been extensively used to create aggregate scores and rankings. OBJECTIVE: To assess the concordance of survey responses provided by patients and clinicians. METHODS: Analysis of 16 pairs of questions that focused on coordination, organizational factors, and patient-centered competencies from the Commonwealth Fund International Health Policy Survey of older adults (2014) and of primary care physicians (2015). Concordance was assessed by comparing absolute rates and relative rankings. RESULTS: In absolute terms, patients and clinicians gave differing responses for questions about coordination of care (patients were more positive) and provision of after-hours care (patients were less positive). In relative terms, country rankings were positively correlated for 5 of 16 question pairs (Spearman ρ > .6 and P < .05). CONCLUSION: Patterns of concordance between patient and clinician perspectives provides information to guide the use of survey data in performance assessment. However, this study highlights the need to assess the complementarity and substitutive nature of patients' and clinicians' perspectives before combining them to create aggregate assessments of performance.

Out-of-pocket expenditure on health care by Australian mothers: Lessons for maternal universal health coverage from a long-established system.

BACKGROUND: Designing effective universal health care systems has challenges, including the use of patient co-payments and the role of the public and private systems. This study sought to quantify the total amount of out-of-pocket fees incurred by women who gave birth in private and public hospitals within Australia-a country with universal health coverage-and assess the impact that variation in birth type has on out-of-pocket fees. METHODS: Data came from a linked administrative data set of all women who gave birth in the Australian state Queensland between July 1, 2012, and June 30, 2015, plus their resultant children. Propensity score matching was used to create two similar cohorts of women who gave birth in private and public hospitals. RESULTS: The mean total out-of-pocket fees for care from conception to the child's first birthday was $2813 (±2683 standard deviation) and $623 (±1202) for women who gave birth in private and public hospitals, respectively. Total fees were higher in both public and private hospitals for women who had a cesarean birth ($716 [±1419] and $3010 [±2988]) than for women who had a vaginal birth without instruments ($556 [±1044] and $2560 [±2284]). DISCUSSION: Australia's strong policy incentives for women to take out private health insurance are leaving women with large out-of-pocket costs. This should hold important lessons for other countries implementing a universal health care system, to ensure that using a combination of public and private practitioners does not undermine the intention of universal care.

Factors associated with successful chronic disease treatment plans for older Australians: Implications for rural and Indigenous Australians.

OBJECTIVE: To identify factors associated with having a successful treatment plan for managing chronic conditions. DESIGN: Secondary analysis of the Commonwealth Fund's 2014 International Health Policy Survey. SETTING: Australia 2014. PARTICIPANTS: A total of 3310 Australian adults over 55 years old. MAIN OUTCOME MEASURES: Whether respondents: (i) had a treatment plan for their chronic condition; and (ii) believed that the plan was helpful in managing their condition. METHODS: We used multiple logistic regressions to assess the association between individual factors (age, income, remoteness, Australian Aboriginal or Torres Strait Islander status) and patient reports of the outcomes of interest. RESULTS: Most respondents reported having a treatment plan for their chronic condition(s); the majority reported that it was helpful in managing their health. Treatment plan provision was associated with age over 75 years, above-average income, Australian Aboriginal or Torres Strait Islander status and multiple chronic conditions. Plans were less likely for residents of outer regional and remote areas. Indigenous respondents were far less likely than non-Indigenous respondents to report that their treatment plan helped a lot. Respondents with providers who 'always' explained things were far more likely to say that a treatment plan helped. CONCLUSION: While the patient-provider relationship influenced the perceived success of treatment plans, inequities in treatment plan provision seemed linked with rurality and income. The higher frequency of treatment plans for Indigenous respondents might reflect access to Australian Aboriginal or Torres Strait Islander health checks, while the plan's perceived lack of efficacy suggests a gap in cultural acceptability.

Who experiences unmet need for mental health services and what other barriers to accessing health care do they face? Findings from Australia and Canada.

PURPOSE: To examine factors associated with unmet need for mental health services and links with barriers to access to care more broadly. METHODOLOGY: The Commonwealth Fund International Health Policy Surveys from 2013 and 2016 were used to explore factors associated with unmet need for adults who experienced emotional distress for 1320 respondents in Australia and 2284 in Canada. FINDINGS: Over one in five adults in Australia (21%) and in Canada (25%) experienced emotional distress, just over half said they received professional help (51% in Australia, 59% in Canada). The majority of those who did not get help indicated did not want to see a professional (37% in Australia, 30% in Canada). For those who did seek help, the factors associated with not receiving care included lower income, higher out-of-pocket health care costs, and poorer health. When compared with people with met needs, those with unmet needs for mental health services were more likely to also experience affordability, medication, and trust-related access barriers (AOR range 2.41 to 7.49 for the two countries, P < 0.01). CONCLUSION: Including unmet needs for mental health services as part of regular reporting on access to care may bring attention to access barriers for people with mental health conditions.

International comparisons of disparities in access to care for people with mental health conditions.

OBJECTIVE: Relatively little is known about experiences of barriers in access to overall care for people with mental health conditions (MHCs), or disparities between people with and without MHCs, or how patterns vary across countries. DATA AND METHOD: The 2016 Commonwealth Fund International Health Policy Survey of adults was used to compare access barriers for people with MHCs across 11 countries, and disparities within countries between people with and without an MHC, using normalized scores. Disparities were also assessed by using multivariable models adjusting for age, sex, immigrant status, income, and self-rated health. RESULT: On average, people with MHCs had a higher prevalence of barriers, with a gap of 7 percentage points between people with and without MHCs. The gap ranged from 5 to 9% across countries. For people with an MHC, the most common access barriers were skipping care due to cost (26%) and receiving conflicting information from providers (26%). For all countries, having an MHC was associated with higher odds of experiencing barriers of access to care on several measures, with at least 1 case where the adjusted odds were greater than 2. CONCLUSION: There is an imperative to improve monitoring of access to overall health care for people with MHCs and an opportunity learn from countries with fewer barriers and disparities in access to care.

Variations in out-of-pocket costs for primary care services across Australia: a regional analysis.

The aim of this study is to describe average out-of-pocket costs across different regions of Australia, as defined by Primary Health Network (PHN) boundaries, and assess the association between population characteristics and out-of-pocket costs for selected primary care services. A combination of descriptive and regression analysis was undertaken using administrative data from the Australian Department of Human Services reporting on the health services used across PHNs in Australia. Those in regional areas paid significantly more for Allied Health services than those in capital cities (A$5.68, P=0.006). The proportion of an area's population aged 65 years and over was inversely related to out-of-pocket charges for Allied Mental Health (-A$79.12, P=0.029). Some areas had both high charges and disadvantaged populations: Country South Australia, Northern Queensland, Country Western Australia, Tasmania and Northern Territory, or populations with poor health: Northern Territory and Tasmania. Although there was a large amount of variation in out-of-pocket charges for primary care services between PHNs in Australia, there was little evidence of inequality based on health, age and socioeconomic characteristics of a population or the proportion of Aboriginal and Torres Strait Islander people.

Out-of-pocket healthcare expenditure and chronic disease - do Australians forgo care because of the cost?

Although we do know that out-of-pocket healthcare expenditure is relatively high in Australia, little is known about what health conditions are associated with the highest out-of-pocket expenditure, and whether the cost of healthcare acts as a barrier to care for people with different chronic conditions. Cross-sectional analysis using linear and logistic regression models applied to the Commonwealth Fund international health policy survey of adults aged 18 years and over was conducted in 2013. Adults with asthma, emphysema and chronic obstructive pulmonary disease (COPD) had 109% higher household out-of-pocket healthcare expenditure than did those with no health condition (95% CI: 50-193%); and adults with depression, anxiety and other mental health conditions had 95% higher household out-of-pocket expenditure (95% CI: 33-187%). People with a chronic condition were also more likely to forego care because of cost. People with depression, anxiety and other mental health conditions had 7.65 times higher odds of skipping healthcare (95% CI: 4.13-14.20), and people with asthma, emphysema and chronic obstructive pulmonary disease had 6.16 times higher odds of skipping healthcare (95% CI: 3.30-11.50) than did people with no health condition. People with chronic health conditions in Canada, the United Kingdom, Germany, France, Norway, Sweden and Switzerland were all significantly less likely to skip healthcare because of cost than were people with a condition in Australia. The out-of-pocket cost of healthcare in Australia acts as a barrier to accessing treatment for people with chronic health conditions, with people with mental health conditions being likely to skip care. Attention should be given to the accessibility and affordability of mental health services in Australia.

Barriers to accessing primary health care: comparing Australian experiences internationally.

Most highly developed economies have embarked on a process of primary health care (PHC) transformation. To provide evidence on how nations vary in terms of accessing PHC, the aim of this study is to describe the extent to which barriers to access were experienced by adults in Australia compared with other countries. Communities participating in an international research project on PHC access interventions were engaged to prioritise questions from the 2013 Commonwealth Fund International Health Policy Survey within a framework that conceptualises access across dimensions of approachability, acceptability, availability, affordability and appropriateness. Logistic regression models, with barriers to access as outcomes, found measures of availability to be a problematic dimension in Australia; 27% of adults experienced difficulties with out-of-hours access, which was higher than 5 of 10 comparator countries. Although less prevalent, affordability was also perceived as a substantial barrier; 16% of Australians said they had forgone health care due to cost in the previous year. After adjusting for age and health status, this barrier was more common in Australia than 7 of 10 countries. Findings of this integrated assessment of barriers to access offer insights for policymakers and researchers on Australia's international performance in this crucial PHC domain.

Publicly financed healthcare and income inequality in Canada.

Income inequality is currently the focus of considerable public and policy attention. Public services such as healthcare and education play a role in reducing income inequality in the population. This study looks at how healthcare affects the distribution of income across five income groups. Specifically, it estimates the tax contributions and the value of benefits received from physician services, drugs and hospital services over a person's lifetime. We found that benefits received from publicly funded healthcare in Canada reduce the income gap between the highest- and lowest-income groups by 16%. This analysis provides a starting point for future research to explore the distributional effects of different options for financing healthcare.