The cost of health care and health insurance in Australia: some problems associated with the fee-for-service system.

This paper reviews the health care system and the supporting health insurance framework in Australia. The importance of the health insurance mechanism is stressed in relation to the maintenance and growth of private fee-for-service medicine. The Medical Benefits Schedule, which is the negotiated basis for medical fees under insurance, is examined for the logic implicit in the fee structure. The high rewards for procedural medicine relative to consulting are suggested as part of the basis of the rapid growth in hospital admissions. It is also argued that the refund schedule has helped to determine the nature of the medical specialist manpower pool. Other problems associated with the complex nature of the refund schedule, such as fraud and wasteful over-servicing, are identified and discussed. It is asserted that the health insurance system and refund schedule are partly determining the nature of medical service provision and inducing inequities in the financing and delivery of medical care in Australia.

Use of operating theatres: the effects of case-mix and training in general surgery.

Details of theatre occupancy times for a surgical unit in a district general hospital and associated cottage hospital were recorded over a 4-month period. The average time of the procedures individually and reclassified within the BUPA schedule showed that both the severity of the procedure and the grade of surgeon influenced future theatre needs. For almost every type of procedure, as expected, consultants were quicker than registrars, who in turn were faster than SHOs. The hidden cost of training surgeons in general surgical operative procedures can be estimated as a result. It is concluded that current measures of resource use which rely only on the bed use and ignore operating theatre needs and training requirements for non-consultant grades will be misleading, particularly in relation to the large element of minor or intermediate surgery which constitutes the bulk of most district health authorities' workload.

Domiciliary care for the elderly sick--economy or neglect?

This paper reports an investigation of the costs of domiciliary care for 139 elderly sick patients under the care of the home nursing service. The data suggest that there may be little economic advantage in home care for seriously disabled elderly people. The revenue cost of domiciliary care was equal to or greater than the average associated with residential or hospital custodial care in such patients. Even so, the cost of services received at home did not disclose the real need for domiciliary care, since at present this is obscured by compulsory rationing and the separation of responsibility between health and social services. It is suggested that the supposed economic advantage of domiciliary care will depend increasingly on restricting such services, thus increasing the degree of neglect to some patients.

The prevalence of stroke in those at home and the need for care.

This paper highlights the severity of disability, social context and care needs of stroke survivors living outside of institutional care. It provides an estimate of the prevalence of stroke in the community, and offers an operational rationale to purchasers of community care services.

Need for supervision in the elderly receiving long-term prescribed medication.

Medication for 127 randomly selected patients aged over 70 in a large group practice was examined in relation to the available supervision for this treatment. About half the patients were on long-term treatment, mainly drugs associated with heart disease, depression, or anxiety. Nineteen had had no recorded contact with the family doctor for six months or longer, and examination by nurse surveillance suggested that three might be suffering from drug toxicity. It was concluded that reliance on self-referral by elderly patients was unsafe.

Extension of family planning service in general practice.

All general practitioners on the list of a single executive council were contacted and 91% were interviewed. They were asked about the type of family planning service currently provided and their willingness to extend the service. Only 3% said that they were not providing any service at the time of interview, but only 4% stated that they provided a complete range of techniques to all patients; almost two thirds of practitioners only provided advice and the "pill". Lack of training in family planning techniques emerged as the most important factor in determining the type of service provided. At the time of interview 64% of doctors stated that they would like further training, and 35% of all doctors asked for a full course of clinical training. Many general practitioners (81%) were willing to extend their family planning services but 65% wanted financial reimbursement and 50% needed additional administrative support as prerequisites.

Computer-held clinical record system. I. Description of system.

An account of a computer system for clinical record, storage, and retrieval is presented. Some details of its design and implementation are described.

Computer-held clinical record system. II. Assessment.

A real-time medical recording system installed in two general medical wards has proved to be unacceptable to many of the ward staff. Reasons for this include operational problems, such as the impossibility of providing a 24-hour service, and conceptual problems, such as the difficulty of adapting the method for recording case histories. It is suggested that an outpatient department might have been a better site for this trial, and that deliberate instruction in medical recording should be given to students as a prerequisite to successful computer record keeping.

Epidemics of procedures: growth in admissions to hospital in Western Australia, 1972 to 1977.

Admissions to hospital, associated with procedures, increased by 20% in Western Australia between 1972 and 1977. This increase in hospital-based procedures appeared to be widespread, both in terms of types of procedures and in terms of age groups of patients. For some procedures the increase was so large as to imitate an "epidemic". Manpower data indicate a parallel growth in practising clinical specialists and the increase in admissions to hospitals. Some suggestions are made about this association and possible causal factors.

Caesarean-section rates in Australia: a population-based audit.

Caesarean-section rates are increasing rapidly in Australia, and in many other Western countries. Private health-fund data for each State of Australia show marked differences in caesarean-section rates between States. Comparison between Western Australia and South Australia showed that these differences could be related to the proportion of specialist obstetricians per capita in each of the States. Although stillbirth rates are lower in the States with high caesarean-section rates, perinatal mortality rates, which include stillbirths, are not significantly different between States. Since the populations of Australian States are reasonably homogeneous, justification for performing more caesarean sections must be questioned.

Occupation and blood pressure.

Australian-born men in low-status occupations have, on average, higher blood pressures than those classified as professional or technical workers, according to the results of a national survey carried out by the National Heart Foundation and the Commonwealth Department of Health, Australia, in 1980. The expected correlations between age, alcohol consumption, body mass, and blood pressure were found. The association between occupation and blood pressure persisted after statistical adjustments for differences in age, obesity, and self-reported alcohol consumption. Though small, the differences in group averages are statistically significant, and suggest the potential for differences of cardiovascular morbidity for workers in different occupations. These findings are consistent with similar gradients in occupational mortality reported in Australia and elsewhere. It is likely that these effects are related to work, both through neuroendocrine stress mechanisms associated with certain job characteristics and through job-determined adverse health-related behaviour. The public health and preventive significance of such associations is stressed.