How do general practitioners view this possible change in financial arrangements?
There are reasons why it may be tempting to think that imposing a copayment for visiting a general practitioner is a good idea. It could instantly reduce the number of GP consultations, perhaps conserving funds for a possibly threatened Medicare. As GPs are “gatekeepers”, and therefore a bottleneck to accessing specialist services, fewer GP services might mean fewer downstream services. It might also be one of several means of reducing overdiagnosis.1 But is it really this straightforward?
Copayments are not new to health: we already encounter them between Medicare and specialist services, between the Pharmaceutical Benefits Scheme and medicines, and between health insurance and private hospital charges. On this basis, insisting that GP services should be “free” seems to devalue GPs. Why should GP services be shouldered with a bargain price while nearly all others charge more? Indeed, many GPs already charge their own “copayment” — arguing (in addition to the obvious pecuniary benefits) that patients will consequently value their care more. Moreover, most GPs are aware that some visits from patients are unnecessary, involving something that could easily have been managed at home, such as a self-limiting acute respiratory infection.
In assessing whether a GP copayment would alleviate any of these problems, there are several key questions to consider — what are the disincentives to visiting a GP; how should we define necessary consultations; and how do we continue to ensure equitable access to health care?
Although a meta-analysis of copayments for pharmaceuticals by the RAND Corporation showed that about 2%–6% of system costs are deterred for every 10% increase in copayment,2 some commentators challenge the idea of extrapolating this to copayments for consultations.3 The converse is apparently not true: making GP visits free for people aged over 70 years in Ireland in 2001 did not cause an increase in GP visits in this group.4 There are already many other disincentives to going to a GP — ringing to schedule an appointment, arranging transport to get there, and the seemingly endless waiting. Thus, for many people, especially the financially secure, a $6 copayment would be a relatively minor disincentive in comparison.
Another difficulty lies with defining “necessary” consultations. Many GP consultations can be summarised as “reassuring the patient”. Are these necessary or not? Helping patients understand that their symptoms can be self-managed is certainly something that does require a consultation. In teaching communication skills to medical students, we spend time emphasising the patient-centred approach — with its evidence of health benefits5 — which starts with eliciting the patient's concerns, fears and expectations. Indeed, without first knowing and addressing these, it can be impossible to stem an ever increasing tide of future consultations and investigations.
Universal access to primary care is one of the essential aspects of our Medicare system and is one of the things that keeps the quality of Australian health care high.6 Among the GP consultations that a copayment would reduce, it is therefore important to consider how many would actually have been necessary. The opportunity for early detection of serious illness may be lost if a person delays or avoids a GP visit because of the copayment. Vulnerable groups, including children, Indigenous people, older people and the financially disadvantaged, may delay seeking treatment for serious illness — or even serious worry — with consequent health compromise. A study in the United States found that doubling primary care copayments from $7 to $14 halved the attendance of people aged 65 years or older, but more than doubled the cost of their inpatient hospital care, from $150 to $330.7
A $6 copayment would undoubtedly deter some people who should visit a GP from doing so, thereby harming them, while others who can afford to pay would be barely inconvenienced. Although a copayment might save a little money in the short term, it would impoverish us all — not just by the downstream increase in specialised health care6-8 and the harm done by missed serious illness and missed opportunities to properly reassure patients, but morally as well.
Provenance: Commissioned; externally peer reviewed.
- 1. Moynihan R, Doust J, Henry D. Preventing overdiagnosis: how to stop harming the healthy. BMJ 2012; 344: e3502.
- 2. Goldman DP, Joyce GF, Zheng Y. Prescription drug cost sharing: associations with medication and medical utilization and spending and health. JAMA 2007; 298: 61-69.
- 3. Gittins R. One card can make it all better. Sydney Morning Herald 2009; 22 Jul. http://www.smh.com.au/federal-politics/one-card-can-make-it-all-better-20090721-drzb.html (accessed Mar 2014).
- 4. Layte R, Nolan A, McGee H, O'Hanlon A. Do consultation charges deter general practitioner use among older people? A natural experiment. Soc Sci Med 2009; 68: 1432-1438.
- 5. Stewart MA. Effective physician–patient communication and health outcomes: a review. CMAJ 1995; 152: 1423-1433.
- 6. Starfield B. Is primary care essential? Lancet 1994; 344: 1129-1133.
- 7. Trivedi AN, Moloo H, Mor V. Increased ambulatory care copayments and hospitalizations among the elderly. N Engl J Med 2010; 362: 320-328.
- 8. Wallace NT, McConnell KJ, Gallia CA, Smith JA. How effective are copayments in reducing expenditures for low-income adult Medicaid beneficiaries? Experience from the Oregon health plan. Health Serv Res 2008; 43: 515-530.