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ANCILLARY AND SPECIALIST HEALTH SERVICES: THE RELATIONSHIP BETWEEN INCOME, USER RATES AND EQUITY OF ACCESS.

Australia's public health system currently provides substantial funding to, amongst its other objectives, ensure access to hospital, medical and pharmaceutical services by all families irrespective of income (McClelland, 1991, p. 6).

However most ancillary, services are not similarly subsidised and there is some evidence that income presents a barrier to the use of these services. There is also evidence that low income might also reduce access to specialist medical practitioner services which, while funded through Medicare, are less likely to be bulk billed than general practitioner services, and which therefore attract higher out-of pocket costs.

In this study, the 1989-90 National Health Survey is used to examine whether there are indicators that low income reduces access to a range of ancillary services such as physiotherapy, optician services, chiropractic and dental services and to specialist medical practitioner services.

Introduction

In Australia, while there is debate about the appropriate mix between public and private delivery of health services, it is nonetheless widely accepted that one of the government's key responsibilities is to ensure the integrity and efficiency of the health system and that services are both widely available and affordable. To this end, tax-payer funded public medical insurance is provided through Medicare and the Pharmaceutical Benefits Scheme. These programs heavily subsidise the cost of `basic' health items, that is, medical practitioner services, hospital services and pharmaceuticals.

Available evidence suggests that services included in these subsidy arrangements are indeed accessible to people from all income groups. For example, a study for the National Health Strategy (1992a, p. 105), reported that `universal coverage has been instrumental in removing barriers to access of health services' and that `access to basic health care services provided under Medicare is equitable'. Scott (1996) found that doctor and hospital services remain equitably distributed by income even after accounting for need.

However, while access to `basic' health services may bc generally equitable, there are indicators that access to other health services might not be so equitably distributed and in particular, that where there are few available public services, low income may present a barrier to their use. These `non-basic' health services include ancillary services (such as dental and physiotherapy services) and specialist medical practitioner services. If access were much less equitable, then it would indicate that Australia's health system is, in effect, two tiered. The first tier would include the heavily subsidised health services which are accessible to the rich and poor alike, and the second, the unsubsidised or less heavily subsidised services which are consequently less likely to be accessible to the poor.

In this context it is significant to note that people on lower incomes have been identified as having poorer health than those on higher incomes (see, for example, National Health Strategy, 1992a, p. 105). If income does function as a barrier to the use of some health services it is therefore likely that this will aggravate some of the existing disadvantages of low income groups.

To determine whether there are indicators that Australia's health services are two tiered, this study examines the distribution of a range of ancillary services and specialist medical practitioner services by people in different income groups. Also examined is the impact of the provision of public services to equity of access.

Income inequality in access to ancillary and specialist health services

There is a small but growing body of evidence which suggests that although programs such as Medicare address potential inequality of access to `basic' health services, there is still serious inequality in terms of access to some health services.

Qualitative research by ACOSS (1993, pp. 26-27, 31), concluded that people on low incomes had difficulty accessing ancillary services, particularly dental care. It was also concluded that the costs of private physiotherapy, chiropractors and a range of natural therapists `placed their care beyond the reach of most participants in the study'. ACOSS's findings on dental care were echoed in a study for the National Health Strategy (1992a, p.82) which also reported that people on low incomes made disproportionally lower use of dental services.

A possible explanation for these findings was provided by McClelland (1991, p. 7, 9) who noted that people on low incomes who used dental and specialist medical practitioner services were spending a significant proportion of their income on these services. Scott (1996) also found that people on low incomes were considerably less likely to use specialist medical practitioner services when compared to people on higher incomes. It was reported that people in the top income quintile were 64% more likely to visit a specialist medical practitioner than those in the bottom income quintile.

In an earlier study, Gibson (1983, pp. 79, 84) focusing on elderly Australians, had also reported a higher probability of using podiatry and dentistry services for people in the highest income category than for people in the lowest. However, Gibson also reported that the poorer aged were not significantly less likely than those on higher incomes to use medical, optical or hearing services (p. 85).

The cost of ancillary and specialist services

In this section, the availability of free publicly provided ancillary services and the cost of using privately provided ancillary and specialist medical practitioner services are examined. This inter-relationship is important as if there are high costs associated with private services, these are likely to reduce access. This is particularly the case for services where there are few free public services or where public ancillary health services have long waiting lists.

An important indicator of the availability of public services is the ratio of the provision of services between the public and private sectors. To examine this ratio, data on public and private employment of health professionals was examined from the 1991 Census.

As Table 1 shows, the proportion of each allied health profession employed by public bodies varies considerably between the professions. More than 95% of chiropractors, osteopaths and dentists work as private practitioners, indicating that these services in particular might be least accessible to people on low incomes. By contrast, only about 50% of physiotherapists and 16% of dietitians were employed privately, indicating that access to these services might be more accessible to low income families.
Table 1.
Employment sector of allied health occupations, Australia, 1991

 Health Sector
 Proportion
Health occupation Public Private private (%)

Chiropractors and osteopaths 10 1470 99.3
Dental practitioners 250 5990 96.0
Podiatrists 170 820 82.8
Physiotherapists 2620 3060 52.0
Dietitians 1029 497 15.9


Sources: Census of Population and Housing (ABS 1993): Dietitian's Association of Australia (at Feb 1990).

To examine the out-of-pocket costs for private services, the schedule fees for `standard' ancillary consultations were obtained from the professional association for each allied health service. (The dental association does not have a schedule of fees, but was able to provide average fees for Australia.) The fees for services examined were found to vary markedly (Table 2). A standard dental visit was the most expensive at $54.90, while a standard visit to a dietitian was the least expensive at $28.00.
Table 2.
Schedule of fees for allied health professionals in private
practice, 1996

Health service Schedule fee($)
Physiotherapy 38.60
Dietitian 28.00
Podiatrist 34.00
Dentist 54.90
Chiropractor 34.00


Note: The schedule fee refers to a `standard session' in NSW. For dental visits this is a single filling, and for other practitioners it is a standard repeat consultation. Fees vary between states and for other types of consultations. These lees are a guide only, and health professionals are free to set their own rates.

Sources: Dietitian's Association of Australia; Australian Physiotherapy Association; Chiropractors Association of Australia: Australian Dental Association: The Australian Podiatry Association.

Fees for services other than standard consultations can be considerably more expensive than those shown in Table 2. In particular, initial consultations were often more expensive (for example, physiotherapy $48.30, dietitian $61 and chiropractor $68), with the exception being an initial dental consultation, which at $30.40 was cheaper than an appointment with treatment. Even more expensive were specialised or long consultations. For example, a crown and bridge cost, on average, $793 in 1995, while a complete set of maxillary and mandibular dentures cost $962.

Some associations include a schedule of fees with a reduced rate for concessional patients, however, the offer of concessional rates is normally at the discretion of each practitioner. This was not the case for dentists, who charge reduced rates for patients covered by certain government programs (such as recipients of Veterans' payments), with these rates being set by the Commonwealth Government.

Turning to the second group of services considered in this study, Medicare subsidised services (private specialist medical practitioners and optometrists), an analysis of the private and public provision of these services showed a high proportion of these practitioners working in private practice. Almost all optometrists (99%) and most specialist medical practitioners (66%) work in private practice. The remaining specialist medical practitioner services are provided free of charge through outpatient clinics at public hospitals.

As optometrist and specialist medical practitioner services are subsidised through Medicare (at a rate of 85% of the schedule fee (HHLGCS, 1993)), income should be less of a barrier than to the non-subsidised ancillary services. However, relatively high out-of-pocket expenses for some of these services may still make them less accessible to low income earners. Commenting on out-of-pocket costs, McClelland observed that a high proportion of income was outlaid by a small percentage of people on low incomes on specialist medical practitioner services as a result of `specialists limited use of direct billing and their greater tendency to charge above the schedule fee' (1991, p. 7, 9).

This pattern was also born out by Medicare statistics for 1995, which indicated that services provided by specialist medical practitioners were less likely than those provided by any other medical practitioners to be bulk billed, at a rate of only about 40% of out-of-hospital patients (Table 3). Plastic surgeons and orthopaedic surgeons were the least likely to bulk bill (14% and 17% of services respectively), while fertility and abortion specialists were the most likely (92% of services). This compared with much higher average rates of bulk billing amongst general practitioners and optometrists (82% and 93% of services respectively).
Table 3.
Fees for Medicare funded out of hospital health services,
Australia, 1995

Health service Proportion bulk Schedule fee Out-of-pocket
 billed (%) ($) cost ($)

Specialist medical
 practitioner 39.8 63.52 16.13
Optometry 93.4 46.85 7.01

General practitioner 81.8 26.21 7.88


Sources: Department of Health and Family Services, Medicare Statistics

Where a patient was not bulk billed, the average out-of-pocket cost associated with a specialist medical practitioner visit was considerably more expensive ($16.13) than for attending a general practitioner or an optometrist ($7.88 and $7.01 respectively). The highest average out-of-pocket costs were recorded for IVF specialists and nuclear medicine specialist services ($29.52 and $25.66 respectively), although some specialties had relatively low average out-of-pocket costs (for example, $8.06 for clinical haematology services).

Who uses ancillary and specialist services?

Methodology and data source

In this section, the question of whether low income presents a barrier to the use of ancillary and specialist medical practitioner services is tested. To determine whether income presented a barrier to the use of ancillary and specialist medical practitioners services, the use of each was analysed across a range of income groups.

Equivalent family income rather than individual income was used as it provides a better indication of available financial resources. Equivalent family income on the NHS is adjusted to account for different family composition and size using the Henderson simplified equivalence scales (Mathers, 1994, p. 71). The gross family incomes were divided into deciles such that the first decile represented the lowest 10 per cent of equivalent family incomes, the second decile the second lowest 10 per cent of equivalent family incomes, and so on.

Use of health services was estimated as the proportion of persons in each income group who used each health service. The estimation of use was age adjusted using least squares means from a series of regression models; which modelled the relationship between the use of health service with age and income. This was done so that the results were not distorted by the clustering of the aged in the lower income groups.

The data source used in the study was the 1989-90 National Health Survey (NHS) conducted by the Australian Bureau of Statistics (ABS, 1990). The NHS is a sample survey of about 55,000 persons and contains a large number of important socioeconomic and health service usage variable, s. It includes persons of all ages, but excludes persons in institutions such as nursing homes.

The NHS includes information on the use of a considerable number of ancillary health services as well as specialist medical practitioner services. The survey indicates whether each respondent had visited a physiotherapist, chiropractor, podiatrist/chiropodist or optometrist in the two weeks prior to the survey, or a dietitian in the 12 months prior to the survey. The survey also recorded the time since the last dental visit. However, it did not include visits to speech pathologists or occupational therapists. This is a significant limitation as a high proportion of these health professionals are in public employment (66% of speech pathologists and 74% of occupational therapists (ABS, 1991)), and it would have been useful to be able to compare the use of these services with those of health providers who are mainly in the private sector.

Visits to specialist medical practitioners were also recorded on the NHS. However, this information was not entirely reliable as the survey recorded only whether the most recent doctor visit in the two weeks prior to the survey was to a specialist medical practitioner. Accordingly, where a respondent visited both a specialist medical practitioner and a general medical practitioner, and the most recent visit was to a general practitioner, the visit to the specialist medical practitioner would not have been recorded. (This is important because persons who reported visiting a specialist in the previous fortnight commonly (29%) reported making two or more doctor visits. This will certainly result in a net under-estimate of the use of private specialist medical practitioner services, and may produce bias in the distribution of the use of these services.)

Dental services

An analysis of information on dental visits in the NHS showed that there was a marked positive relationship between income and dental visits. People from the lowest income families reported just over half the incidence of dental visits over a six months period when compared to persons from the highest income group (19% and 34% respectively) (Figure 1).

[Figure 1 ILLUSTRATION OMITTED]

The apparent income barrier to dental services is probably directly related to the cost of dental care, as over 95% of dentists work in private practice and their fees are the highest of any ancillary health service (see Table 2). The availability of public dental services can be expected to be substantially reduced with the immediate cessation of the Commonwealth Dental Programme leading to a cut in expenditure on public dental services of $112.8 million in 1997-98 (Commonwealth of Australia 1996, p. 149).

Gaughwin et. al. (1996) report that there is empirical evidence that inadequate dental care among children from low income families results in poorer dental health (measured by such factors as untreated decayed tooth surfaces and missing teeth) when compared to children from higher income families. Accordingly, income barriers to dental care have been linked to poor dental health.

The results of this study are also consistent with findings reported by ACOSS (1993), the Australian Institute of Health and Welfare (AIHW, 1996) and the National Health Strategy (1992a) who also found that dental services were less accessible to people on low incomes.

The Australian Institute of Health and Welfare (1996, p. 174-7) suggests that not only do people on low incomes visit the dentist less often, but that they are also more likely to wait until a dental problem emerges, losing the benefits of early detection from regular check ups and preventive care. In addition, there may be a further wait for treatment for patients attending a public dental clinic. It was found that 21% of public dental patients waited more than six months for a dental checkup and 11% waited more than six months for an appointment to treat an existing problem.

Chiropractic services

An analysis of the use of chiropractic services by different income groups revealed a pattern similar to that of dental care. It was found that people on low incomes were about half as likely to visit a chiropractor as those on the highest incomes (Figure 2). The lowest incidence was amongst people in the second equivalent family income decile (0.7%) with the highest being amongst those in the top equivalent family income decile (1.8%).

[Figure 2 ILLUSTRATION OMITTED]

These findings are consistent with those of ACOSS (1993) who reported that access to chiropractors by low income earners was limited. They were seen as `helpful health care practitioners, yet unaffordable.'

This result is not surprising as, like dentists, almost all chiropractors work in private practice and out-of-pocket costs are considerable at $34.00 per

standard treatment.

Dietitian services

The pattern of use of dietitian services was found to be the reverse of most other ancillary services included in this study. Persons from low income families were more likely to visit a dietitian (2.0% of persons from the second equivalent family income decile) than high income earners (1.2% of persons from the top equivalent family income decile). However, people from the sixth equivalent family income decile were the least likely to use the services of a dietitian (0.8%).

There are two probable reasons for the higher use of dietitian services by people with low incomes. The first is the relatively low proportion of dietitians in private practice (16%). This is the lowest proportion of private employment amongst any of the health providers included in this study and indicates that obtaining dietitian services at no cost is much easier than for other services.

The second reason is that people on low incomes may also have a greater need of dietitian services. First, they are more likely to be overweight. This is particularly the case amongst women from low income families, where 38% of low income women are overweight compared to 26% of women from high income families (Mathers, 1994, p. 79). Second, poverty is considered the `most difficult barrier to better nutrition, and those people with the least disposable income are at the greatest risk of poor nutrition' (Lester, 1994, p. 250). Third, people on lower incomes have a higher incidence of diabetes than people on higher incomes including where the condition is managed by diet alone (Meadows, 1995).

Physiotherapy

As figure 4 shows, there is no clear relationship between physiotherapy and income. The groups who were least likely to receive physiotherapy were the middle income earners, with the lowest incidence of 1.3% amongst people in the sixth equivalent family income decile. However, people with low family incomes were somewhat less likely to have physiotherapy treatment that those on higher incomes (1.3% visiting from families in the bottom equivalent family income decile compared to 2.2% from families in the top equivalent family income decile).

[Figure 4 ILLUSTRATION OMITTED]

One reason why income may not appear to present such a barrier to the use of physiotherapy services is the relatively high proportion of physiotherapists (about 50%) who provide services from within the public health system (ie. at no direct cost to the user).

In addition, a reasonably high proportion of private patients are treated without incurring out-of-pocket costs as their treatment is paid for through worker's compensation and insurance related to motor vehicle accidents (approximately 35% of private physiotherapy caseloads (Australian Physiotherapy Association, unpublished)).

Unfortunately, the NHS does not identify which patients incur out-of-pocket costs, limiting the ability of the analysis in this study to identify income barriers to treatment for patients who must pay for their own treatment.

Podiatry and chiropody services

There was a slightly higher use of podiatry and chiropody services in the two weeks prior to the NHS survey amongst higher income earners (1.4% of persons in the top equivalent family income decile) than amongst low income earners (1.0% of persons in the bottom equivalent family income decile). The lowest reported use of podiatry and chiropody services was amongst persons in the third equivalent family income decile (0.8%).

The relatively small increase in the use of podiatry and chiropody services as income increased is surprising as over 80% of podiatrists work in private practice. The explanation for this finding may well be that there is little public awareness of podiatry services, with podiatrists representing only 0.4% of the health work force in 1991 (AIHW, 1996, p. 140). Accordingly, even patients who can afford to attend a private podiatrist might not seek treatment because they do not know that it exists. It is, therefore, possible that low income does present a barrier for low income earners who do need treatment, and are aware that it is available. There is also only limited access to publicly provided services, in that these clinics are not universally available, but are limited to aged pensioners and diabetics.

Optometry

While there is a positive relationship between the use of optometry services and income (Figure 6), the pattern is much less pronounced than for some other ancillary services (most notably, dental services). About 1.8% of people on the lowest family incomes visited an optometrist in the two weeks prior to the NHS compared to 2.3% of people on the highest incomes. The relative equality of use of optometry services probably results from Medicare funding of optometry services and the high proportion of optometry services which are bulk billed (93%). The slight trend towards higher use amongst people on higher incomes might result from the associated cost of frames and lenses rather than optometry costs.

[Figure 6 ILLUSTRATION OMITTED]

Specialist medical practitioner services

Analysis of the use of specialist medical practitioner services by income indicated that people on low (and middle) incomes were considerably less likely to use these services than were people on high incomes (3.0% of persons in the bottom equivalent family income decile compared to 4.2% of persons in the top equivalent family income decile) (Figure 7). The pattern of specialist use however, is interesting in that there is relatively little difference in the use of specialist medical practitioner services between the low and middle income groups, with a sharp increase for the top two income deciles. These findings are consistent with those of McClelland (1991) and Scott (1996) who also reported that people on lower incomes had a lower use of specialist medical practitioner services than those on higher incomes. The positive relationship between use of specialist medical practitioner services and income is notable in its contrast with the pattern of use of general medical practitioner services - where the poor are more likely to visit a GP than the more well off after adjusting for the affect of age (20.6% of persons in the bottom equivalent family income decile compared to 17.9% of persons in the top equivalent family income decile (ABS 1989-90 National Health Survey)). These opposing patterns are of particular interest because the use of both general medical practitioners and specialist medical practitioners are subsidised through Medicare.

[Figure 7 ILLUSTRATION OMITTED]

The relatively poorer access for people on low incomes to specialist medical practitioners compared to general medical practitioners probably results from three main factors. First, specialist medical practitioner services are much less likely to bulk bill compared to general medical practitioners services (40% and 82% respectively).

Second, out-of-pocket costs associated with non-bulk billed specialist medical practitioners are considerably higher than those associated with general medical practitioners ($16.13 and $7.88 respectively).

Third, the limited use of private specialist medical practitioners by people on low incomes is, in fact, counterbalanced by their greater use of outpatient services, where treatment is provided free of charge. A survey of general medical, arthritis and cardiology outpatient clinics in six hospitals (National Health Strategy, 1992b, pp. 94-97) indicated that people in the lowest income group in this study (less than $12,000 per annum) represented about 45% of outpatients while people in the highest income group (over $5;0,000 per annum) represented only about 5%.

Conclusions

This study sought to determine whether income presented a barrier to the use of some health services, and if so, to identify those services which might, for this reason, form a second tier of services which were less accessible to the poor.

An analysis of the 1989-90 NHS indicated that income appeared to present a particular barrier to the use of dental, chiropractic and private specialist medical practitioner services. High out-of-pocket expenses associated with private practitioner services, coupled with a limited supply of public services were identified as the probable cause of this income barrier.

However, not all of the services studied in this paper were found to be inequitably distributed amongst the income groups. There was no evidence of an income barrier to the use of dietitian and physiotherapy services, while the use of optometry services was only slightly skewed towards the higher income groups.

The more equitable distribution of dietitian and physiotherapy services was attributed to a high proportion of services being provided at no cost through the public sector. For optometry, the relatively equitable use of services by the poor was considered to be a result of out-of-pocket costs being reduced through a Medicare subsidy combined with a high rate of bulk-billing.

This study demonstrates the importance of a balance between the provision of public and private services when equity issues are being considered, and highlights a number of policy considerations. First, it is important to monitor public expenditure and labour force numbers for allied health services. Maintenance of public funding and adequate staff numbers should ensuring that public services remain accessible to people who cannot afford private treatment. In particular, the impact of the cessation of the Commonwealth Dental Programme should be examined to determine, whether it leads to reduced access to dental care among the poor and associated poorer dental health. Second, there is a need to determine whether existing public services are distributed so that they are easily accessible to residents of low socioeconomic areas.

Third, there is a need to examine whether the recently introduced private health insurance rebate has an impact on the level of ancillary insurance amongst low and middle income families, and whether this flows on to greater access to health services, such as dental care, provided mainly through the private sector.

Finally, high out-of-pocket costs have been identified as a barrier to the use of some services, while other services attract relatively low out-of-pocket expenditure. There was marked inconsistency in out-of-pocket costs between different service types with some services heavily subsidised or provided mainly through the public sector, while others were almost entirely provided by the private sector. This suggests the need for a review of the balance in public funding between health service types and the need to systematically review patient expenditure as an ongoing measure of affordability of care.

Accepted for publication: February 1998

[Figures 3 & 5 ILLUSTRATION OMITTED]

References

Australian Bureau of Statistics (1990), 1939-90 National Health Survey, Unit Record Data Catalogue No. 4324.0, Australian Bureau of Statistics, Canberra.

Australian Bureau of Statistics (1993), Characteristics of persons employed in health occupations, Australia., Catalogue No. 4346.0, Canberra.

Australian Council of Social Services (1993), Poverty is a health hazard.

ACOSS Research Paper No. 7. Australian Council of Social Services Sydney.

Australian Institute of Health and Welfare (1996), Australia's health 1996: The fifth biennial report of the Australian Institute of Health and Welfare. AGPS, Canberra.

Commonwealth of Australia (1996), Facts Sheet, Budget 1996-97, Department of Health and Family Services. AGPS, Canberra.

Gaughwin A D Brennnan J Spencer and J Moss (1996), `The Study into the Child Use of Dental Health Services in South Australia', Research Study Report, Dental Statistics Research Unit, University of Adelaide, Adelaide. Gibson D (1983), `Utilization of medical and paramedical services', in Kendig H, D Gibson, D Rowland and J Hermer (1983), Health, welfare and family in later life, New South Wales Council on the Ageing, Sydney.

Department of Health, Housing, Local Government and Community Services (1993), Medicare Benefits Schedule Book., AGPS, Canberra.

Lester 1 (1994), Australia's food and nutrition., Australian Institute of Health and Welfare, AGPS, Canberra.

McClelland A (1991), Spending on health: The distribution of direct payments for health and medical services. Background Paper No. 7, July, National Health Strategy, Canberra.

Mathers C (1994), Health differentials among adult Australians aged 25-64 3, ears, Health Monitoring Series No. 1. Australian Institute of Health and Welfare, AGPS, Canberra.

Meadows P (1995), `Variation in diabetes mellitus prevalence in general practice and its relation to deprivation'. Diabet. Med. 12 (8), 696-700.

National Health Strategy (1992a), Enough to make you sick. Research Paper No. 1, September, National Health Strategy, Canberra.

National Health Strategy (1992b), A study of hospital outpatient and emergency department service. Background Paper No. 10, June, National Health Strategy, Canberra.

Scott M (1996), `Equity in the distribution of health care in Australia', Paper presented at the 18th Annual Conference of the Australian Health Economics Society, July, Coifs Harbour.

Deborah Schofield, Director, Modelling Unit, Strategic Analysis and Education Branch, Department of Family and Community Services, PO Box 7788, Canberra Mail Centre ACT 2601
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Author:Schofield, Deborah
Publication:Australian Journal of Social Issues
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