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Costs force ill to skip care

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Almost half of patients with depression, anxiety or other mental health conditions and a third of those suffering asthma, emphysema and other chronic respiratory illnesses are skipping treatment because of out-of-pocket costs.

As the Medicare rebate freeze forces a growing number of general practices to cut back on bulk billing and increase patient charges, researchers have found that out-of-pocket costs for medical services and medications are deterring many with chronic illnesses from seeing their doctor or filling their prescription, potentially making their health problems more difficult and costly to treat.

They found that those with mental illnesses were the most price sensitive – 44 per cent reported deferring an appointment or leaving a script unfilled because of cost, as did 32 per cent with asthma or chronic obstructive pulmonary disorder and 27 per cent of those with diabetes. Even a fifth of cancer patients reported skipping treatment because of the expense.

Out-of-pocket charges were cited as a barrier to care even for some of those without a long-term health problem – 9 per cent said deferred care because of cost.

Lead researcher Dr Emily Callander from James Cook University said that although, as a whole, Australia enjoyed good health outcomes, her study showed that out-of-pocket costs were a substantial barrier to care, particularly for vulnerable and at-risk patients like the chronically ill.

She said the problem was particularly acute for patients with mental health problems.

“Those with mental health conditions were shown to have particularly large out-of-pocket expenditure and be more likely to forgo care, which indicates that the costs of mental health services may be prohibitively high,” Dr Callander and her colleagues wrote.

Out-of-pocket costs high

The research, which is part of an international Commonwealth Fund health policy study and draws on data from a NSW Bureau of Health Information survey of 2200 respondents, found that out-of-pocket expenses for Australia patients were high by world standards.

It showed that Australians paid an average of $1185 in out-of-pocket costs, compared with $987 for Germans, $947 for Canadians, $639 for New Zealanders, $488 for British patients and $421 for the French.

Dr Callander’s said research showed expenses for patients with chronic illnesses can be particularly high.

Stroke survivors, for example, spent an average of $1110 a year on health costs, including up to $32,411 in the first 12 months following their stroke. Those with arthritis, meanwhile, paid out an average of $1513 a year on treatment, with some spending as much as $20,527.

Those with asthma, emphysema and COPD reported spending an average of $1642 a year on out-of-pocket expenses, while those with a mental illness spent $1350 a year and those with high cholesterol spent $1423 annually.

By comparison, those without a chronic illness spent on average $660 a year on out-of-pocket health costs.

Dr Callander said the point of her research was not that out-of-pocket costs were inherently wrong, but could have a much more significant effect on vulnerable patients, like the chronically ill, than the broader community.

“I don’t think that out-of-pocket costs per se are a bad thing,” the researcher said. “I am not saying that we should not have them.

“But while maybe a $30 GP out-of-pocket charge might not seem much to most of us, for someone with a chronic disease who is unemployed it might seem a lot. For them it might mean a choice between seeing the doctor or having some extra food.

“It is the disadvantaged – the people with low incomes and ones with chronic health problems – who are the worst affected.”

Chronic catch-22

The chronically ill are caught in a double-bind. They often face much higher health expenses than most, while the effect of their illness is often to make it difficult for them to work.

Dr Callander said it was well documented that people with chronic illnesses were on lower incomes, had less wealth, and were more likely to be in income poverty, “which is likely because of the effect that chronic health conditions have on their ability to participate in the labour force”.

And, of course, the more they defer or forgo treatment, the worse their health becomes and the more expensive the treatment required.

Dr Callander’s research found that the combined effect of high out-of-pocket expenses and low incomes was to force 25 per cent of chronically ill Australians to skip care, exceeded only by the United States, where 42 per cent of patients with a chronic illness said they deferred treatment because of cost. By comparison, just 8 per cent of chronically ill Swedish patients and 5 per cent of British patients admitted to the same thing.

While in the past research had concentrated on a lack of available services as a common barrier to care, Dr Callander said the effect of cost had often been overlooked.

“The [study shows] that the cost of health care does act as a barrier to receiving treatment, particularly for those with mental health conditions,” the researcher said. “These findings come at a vital time when there has been much discussion abour the possibility of raising the cost of healthcare to individuals.”

She said it was of “vital importance” that there be policies aimed at promoting affordable health care for at-risk and vulnerable patients, “to ensure that out-of-pocket cost is not a barrier to treatment and do not widen the gap in health status between those of high and low socioeconomic status”.

The study has been published in the Australian Journal of Primary Health.

Adrian Rollins