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To be, or not to be…

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Recently I saw Hamlet at Sydney’s Belvoir Theatre. As the blurb says ‘Director Simon Stone is ruthless and visionary in his pursuit of the essential in a text; Toby Schmitz [Hamlet] is one of the great actors of his generation: quick, droll and fiendishly sharp.’ I admit no conflict of interest: it is simply brilliant. In Hamlet’s day, all was not well in the state of Denmark.
Coincidentally, Crown Prince Frederik and Crown Princess Mary, members of today’s royal court of Denmark, were in town for the 40th birthday celebrations of the Sydney Opera House, its architect being the great Dane, Jørn Utzon. Their generous visit to the Winmalee fire victims in late October was matched by Mary’s gift of her bouquets to patients in Westmead Hospital’s cancer centre named in her honour in 2011. The state of Denmark was looking good.

The complexity of large institutions, be they Denmark or Medicare, is that simultaneously you can find in them both healthy and unwell bits. Medicare still removes financial barriers to medical and hospital care in Australia, but other parts of it are problematic.

MJA InSight, an on-line news and commentary channel affiliated with The Medical Journal of Australia, recently conducted a poll among readers about Medicare. Should the new federal government undertake a major review of Medicare, readers were asked.

The voting options and responses were as follows: Yes, long overdue – 75 per cent; yes, with reservations – 28 per cent; no, leave it alone – 22 per cent.

All is not well in state of Medicare, at least as viewed by the readers of MJA InSight.

Now, I fully accept that these opinions are not representative of all doctors or of Medicare users. Let’s regard them as indicators. What might the new Federal Government consider were they to undertake a major review of Medicare?

I asked Dr Anne-marie Boxall, director of the Deeble Institute for Health Policy in Canberra and co-author, with policy academic Jim Gillespie, of a new book entitled Making Medicare, for her ideas. Her book chronicles the evolution of Medicare from its inception as Medibank to the present.

Dr Boxall suggested that a thoroughgoing review of Medicare was warranted, and should consider three related priorities.

First, the relation between Medicare and private health insurance should be reassessed. Health care in Australia is funded and delivered by both the public and private health sectors, frequently in combination. They are not discrete and unrelated systems and, to avoid inefficiencies, insurance for access to both public and private care should be considered together.

Second, a critical review is needed to ascertain what is really happening about access to care. Medicare at present assures access to many services without charge – bulk billing general practitioners and public hospitals, for example. But many other vital health care services are not funded through Medicare, or incur an additional cost. The limitations of Medicare, particularly in the management of chronic illness, and in the private sector, should be defined, and creative ways searched out to improve access to care. These new ways may be financial, but are likely to include new policies for medical workforce development and deployment.

Third, and none-the-less important for that, the new Federal Government would do well to ensure that a review of Medicare takes the matter of quality in health care seriously. The original purpose for Medicare was to enable unfettered access to health care. It was not designed to deal with what happened when access was achieved, what went on in the therapeutic transactions to which it gave access.

But the scene has changed, and the close association between paying for care and assuring quality is much more in focus worldwide.

Medicare contains no incentives to improve the quality of patient care. Over time, governments have tried to stimulate quality improvements, but these have stood alongside financing arrangements rather than being supported by them.

Medicare remains an icon of Australian health care. But all is not well within its estate. Clever diagnosis and the correct prescription are needed to bring the system back to better health.