An important Australian initiative that sets an international precedent
We’ve got major problems at a really early age . . . to do these elderly health assessments, are they going to dig us up? We’re dead and buried by then. We might as well set up a clinic next to the cemetery.1
These poignant words were spoken by Dr Puggy Hunter, recipient of the Human Rights and Equal Opportunity Commission’s Human Rights Medal in 2001 and former Chair of the National Aboriginal Community Controlled Health Organisation (NACCHO), who passed away at the age of 50 years in 2001. He made these observations after the federal government’s launch of the Enhanced Primary Care Package in November 1999. Among other things, the package was designed to assist general practitioners to provide preventive care for Australians over the age of 75 years through Medicare Benefits Schedule rebates. For Aboriginal or Torres Strait Islander people the age limit was lowered to over 55 years.2
As 53% of Aboriginal men and 41% of Aboriginal women die before reaching the age of 50 years,3 representatives from NACCHO,4 general practice groups and the Australian Medical Association expressed concern that relatively few Aboriginal people would benefit from these rebates. Moreover, an evaluation in 2003 found that few Aboriginal and Torres Strait Islander people over 55 years had accessed the Enhanced Primary Care rebates.5
In this population, preventive health assessments are obviously needed earlier, given the occurrence of preventable chronic disease at younger ages and higher rates than in other Australians.6 Preventive healthcare can both reduce costs to the health sector and enhance health equity for Aboriginal peoples and Torres Strait Islanders, as most of the factors underpinning health disparities relate to social disadvantage (Box). For example, if renal disease is detected early, end-stage renal failure can be avoided and treatment will reduce mortality by 50%.12 However, during 1997–2002, Aboriginal and Torres Strait Islander Australians (compared with non-Indigenous Australians) were twice as likely to be referred late for dialysis treatment. (Late referral is defined as first attending a renal unit or being seen by a nephrologist less than 3 months before the initiation of dialysis.)
In the intervening years, NACCHO has lobbied hard for the Medicare Benefits Schedule to make preventive health checks accessible to younger Aboriginal people.4 On 5 May 2004, the Federal Minister for Health launched a new Medicare Benefits Schedule rebate for an adult health check of Aboriginal and Torres Strait Islander people aged 15–54 years (Item 710).13
The challenge now is for GPs to make use of this rebate. Firstly, they need to understand what comprises an effective preventive health assessment for this population. In 2001, NACCHO led an alliance of eight non-government organisations — the Chronic Disease Alliance — to undertake a review of the evidence for preventive interventions, with the support of the Royal Australian College of General Practitioners and the Australian Government Department of Health and Ageing. The outcome — The national guide to a preventive health assessment in Aboriginal and Torres Strait Islander peoples — was completed in 2004,6 and a pilot study has been conducted with over 40 GPs. The guide lists a range of health problems and risk factors that are amenable to prevention, and supplements the “red book” of the Royal Australian College of General Practitioners.14 It takes into consideration the differing demographic and epidemiological factors that influence the development of disease in Aboriginal and Torres Strait Islander populations and was the basis for the descriptor for the new rebate.
Secondly, changing practice to align with the evidence requires more than guidelines. Multifaceted strategies are needed, including decision-support systems, clinical audit, feedback, and support from opinion leaders.15 A health system that relies on free market provision of preventive healthcare can perpetuate inequity, as those who need the interventions are least able to afford and access the provisions. Proactive encouragement of preventive health assessments requires incentives and penalties, as well as removal of administrative and legislative barriers.
Even with the rebate, implementing adult health checks in general practice may not be easy. According to 2001–02 data from the BEACH study (Bettering the Evaluation And Care of Health), at least 70% of GPs in Australia have, to their knowledge, not provided care for a single Aboriginal or Torres Strait Islander person in that period.8,9 Thus, changing practice to maximise the uptake of adult health checks for this population will require a range of supportive activities, such as:
Distributing the guide to every GP;
Promoting a suite of resources to assist GPs to better identify Aboriginal or Torres Strait Islander people and to improve cross-cultural communication;13
Developing ancillary resources such as case studies;
Upskilling GPs using the expertise of Aboriginal community-controlled health services through coordinator positions established within NACCHO affiliates;
Enhancing and supporting the role of Aboriginal health workers;
Introducing clinical audit points for professional development.
Bulk-billing for these assessments is critically important given the significant socioeconomic disparity between Aboriginal and Torres Strait Islander people and the broader Australian population.16 Mechanisms for improving access to medications under the Pharmaceutical Benefits Scheme for Aboriginals and Torres Strait Islanders are also required. This has been proposed by the Australian Pharmaceutical Advisory Council, NACCHO, the AMA and the Pharmacy Guild in a series of new reforms.17
2004 is the final year of the United Nations International Decade of the World’s Indigenous Peoples, and the development of this Medicare Benefits Schedule rebate removes a significant cost barrier from the delivery of preventive healthcare to Australian Indigenous people. The adult health check is an important Australian initiative that sets an international precedent. A total of 1977 services were claimed against Item 710 (Health Insurance Commission data18) from May to August 2004. This appears slower than the initial claim rate of elderly health assessment items (Enhanced Primary Care) for which an extensive implementation strategy was funded by the government. It is now time to finance an appropriate implementation strategy for the adult health check. General practice groups, including Divisions, should assist GPs to use the new adult health-check rebate for the identification and timely management of unrecognised health problems among Aboriginal and Torres Strait Islander Australians — the populations in which this is most urgently needed.
Justification for a Medicare Benefits Schedule rebate for adult health checks for the Aboriginal and Torres Strait Islander population
Aboriginal people and Torres Strait Islanders:
have lower participation rates in preventive health programs (eg, cervical screening and breast cancer detection).7
have high rates of undetected risk factors and chronic disease.6
are referred late for end-stage disease, making treatment options more expensive (eg, if renal failure develops).6
are less likely to ask for preventive health assessments (significantly lower rates of requests for check-ups).8
have unequal access to Medicare (rate of use of the Medicare Benefits Schedule by Aboriginal people and Torres Strait Islanders is less than half that of other Australians, yet their overall health needs are about three times greater).9
miss opportunities for prevention (eg, significantly lower rates of vaccination by GPs in encounters with Aboriginal and Torres Strait Islander people10), leading to higher rates of hospital admissions for preventable diseases.11
find the preventive assessment process complex (comorbidity, sociocultural considerations).6
experience difficulties in delivering preventive healthcare to the Aboriginal and Torres Strait Islander population (inadequate remuneration for the time required, lack of knowledge of relevant health issues and inability to identify Indigenous Australians).6
- 1. National Aboriginal Community Controlled Health Organisation/Australian Divisions of General Practice Limited. Report on the Joint NACCHO–ADGP Workshop on Education and Training Strategies for new Medicare Items (EPC) for Aboriginal Community Controlled Health Services. Canberra May 8-9, 2001. Available at: http://www.naccho.org.au/Workshop.html (accessed May 2004).
- 2. Australian Government Department of Health and Ageing. Enhanced primary care package. Available at: www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-epc-index.htm (accessed Oct 2004).
- 3. Australian Bureau of Statistics. Mortality of Aboriginal and Torres Strait Islander Australians. Occasional Paper, 1997 (Catalogue No. 3315.0.) Canberra: ABS, 1997. Available at: www.abs.gov.au (accessed June 2004).
- 4. National Aboriginal Community Controlled Health Organisation. Medicare Rebate for the health assessment of Aboriginal and Torres Strait Islander persons — proposal to benefit Aboriginal health. Submission to the Commonwealth Department of Health and Aged Care, Medicare Benefits Branch, May 2001. Available at: www.naccho.org.au/medicare.html (accessed Jun 2004).
- 5. Wilkinson D, Mott K, Morey S, et al. Evaluation of the Enhanced Primary Care (EPC) Medicare Benefits Schedule (MBS) Items and the General Practice Education, Support and Community Linkages Program (GPESCL) — final report. Canberra: Australian Government Department of Health and Ageing. Available at: www.health.gov.au/epc/epcevaluation.htm (accessed June 2004).
- 6. National Aboriginal Community Controlled Health Organisation and the Chronic Disease Alliance of Non-Government Organisations. National guide to a preventive health assessment in Aboriginal and Torres Strait Islander peoples. Royal Australian College of General Practitioners and Australian Government Department of Health and Ageing, 2004. In press.
- 7. Public Health Outcome Funding Agreements between the Commonwealth of Australia and Western Australia. Performance Report for Year 2, 2000-01. Available at: www.health.gov.au/pubhlth/about/phofa/wa.htm (accessed Sep 2004).
- 8. Britt H, Miller GC, Knox S, et al. General practice activity in Australia: 2001-02. Canberra: Australian Institute of Health and Welfare, 2002: 121. (AIHW Catalogue No. GEP 10.)
- 9. Australian Institute of Health and Welfare. Expenditures on health services for Aboriginal and Torres Strait Islander people 1998–99. AIHW Catalogue no. AIHW 7. Canberra: Australian Institute of Health and Welfare and Commonwealth Department of Health and Aged Care, 2001. Available at: www.aihw.gov.au/publications/ihw/ehsatsip98-99/ (accessed Sept 2004).
- 10. Britt H, Miller GC, Knox S, et al. General practice activity in Australia: 2002–03. (AIHW Catalogue No. GEP 14.) Canberra: Australian Institute of Health and Welfare, 2003: 127.
- 11. Stamp KM, Duckett SJ, Fisher DA. Hospital use for potentially preventable conditions in Aboriginal and Torres Strait Islander and other Australian populations. Aust N Z J Public Health 1998; 22: 673-678.
- 12. Hoy WE, Wang Z, Baker PR, Kelly AM. Secondary prevention of renal and cardiovascular disease: results of a renal and cardiovascular treatment program in an Australian Aboriginal community. J Am Soc Nephrol 2003; 14 (7 Suppl 2): S178-S185.
- 13. Australian Government Department of Health and Ageing. Enhanced Primary Care: Medicare Benefits Items. Available at: www.health.gov.au/epc/atsiinfo.htm (accessed June 2004).
- 14. Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 5th ed. Melbourne: Royal Australian College of General Practitioners, 2002. www.racgp.org.au/ (accessed June 2004).
- 15. National Health and Medical Research Council. How to put the evidence into practice: implementation and dissemination strategies. Canberra: MHMRC, 2000.
- 16. Altman J. The economic and social context of Indigenous Health. In: Thomson N, editor. The health of Indigenous Australians. Melbourne: Oxford University Press, 2003.
- 17. Australian Pharmaceutical Advisory Council. Outcome statement. Meeting 17–18 June 2004. Available at: www.health.gov.au/internet/wcms/Publishing.nsf/Content/nmp-publications-apac.htm (accessed October 2004).
- 18. Medicare Benefits Schedule (MBS) Items statistics reports. Services for Item 710. May–August 2004. Available at: www.hic.gov.au/statistics/dyn_mbs/forms/mbs_tab4.shtml (accessed October 2004).
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