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Health policy
Beyond Structural Neglect: Using Evidence to Strengthen Primary Health Care Systems, Policies and Programs for Aboriginal and Torres Strait Islander Men
Despite decades of policy focus, Aboriginal and Torres Strait Islander men still face primary health care systems that are misaligned with their cultural and social needs, leading to low use. A strong body of evidence shows engagement improves when care is culturally safe, gender-responsive and community-led, yet these are inconsistently implemented. Short-term funding and fragmented commissioning undermine continuity, workforce stability and holistic care. Reliance on pilot programs reflects risk aversion and limits reform. Redesigning commissioning to ensure long-term funding, a stable workforce, stronger governance and learning-focused evaluation is essential. Continued delay perpetuates inequity, making reform an ethical and political imperative.
Kootsy Canuto, Celina Gaweda, James Smith, Karla J. Canuto
From Ambition to Action: Closing Policy, Equity and Implementation Gaps in the Australian Cancer Plan's ‘Enhanced Consumer Experience’
Despite advances in cancer treatment, many Australians experience fragmented, poorly coordinated care, particularly those who are most disadvantaged. Strategic Objective 2 of the Australian Cancer Plan commits to improving consumer experience through person-centred, culturally safe, coordinated care across the continuum, yet implementation remains inconsistent. This perspective article examines key challenges, including siloed services, inequitable access to navigation and supportive care and poorly actioned experience measures. We propose scalable solutions: patient decision support tools, equity-oriented navigation and real-time experience measures. Realising this vision requires sustained investment strategies and system integration.
Carla Thamm, Elise Button, Oluwaseyifunmi A. Agbejule, Reegan Knowles, Karen van Gorp, Mark B. Pinkham, Meinir Krishnasamy, Alexandra L. McCarthy, Raymond J. Chan
Prediabetes: The Looming Burden for Australia
Diabetes is fast becoming the key health concern for Australia, with a substantial national increase in prevalence and an estimated 10% or more of adults living with the disease. Evidence shows that over half of this disease burden can be prevented by identifying prediabetes and providing appropriate interventions early. However, Australia currently has no accurate estimates of prediabetes prevalence, and no clear strategy on how to act when prediabetes is identified in clinical practice. This article lays out the problem, with potential solutions for government and the community.
Gideon Meyerowitz-Katz, Sarah N. Parry, Tien-Ming Hng, N. Wah Cheung, Alice A. Gibson, Emily J. Hibbert, Kean-Seng Lim, Eugen Molodysky, Glen Maberly, Louise A. Baur, Stephen M. Twigg
Pharmaceutical Industry Payments to Patient Groups in Australia: A Longitudinal Analysis of a Decade of Disclosures
Objectives To analyse the extent and patterns of pharmaceutical industry funding of patient groups in Australia between 2013 and 2022, including the proportion of groups' income derived from industry payments in 2022.Study TypeLongitudinal observational study.Setting, ParticipantsAustralia, 1 January 2013–31 December 2022. Public disclosures of payments to patient groups from pharmaceutical companies who were members of Medicines Australia (the trade organisation for the prescription pharmaceutical industry in Australia) between 2013 and 2022 and from non-member companies with at least five registered prescription products in Australia.Main Outcome MeasuresValue (in Australian dollars) of reported payments to patient groups from the pharmaceutical industry and trends in payments by clinical area and over time. For patient groups that received industry funding in 2022, we also examined how this compared with their total income for that year.ResultsBetween 2013 and 2022, 45 pharmaceutical companies disclosed $95.7 million in funding to 390 patient groups. Funding was highly skewed, with 13 groups receiving 47.9% ($45,856,940/$95,724,493) of the total payments. The median funding over the decade was $34,374 (interquartile range [IQR], $8228–$122,898) per group. The total reported payments decreased by $293,246 (95% confidence interval, $125,489–$461,006) per year, but some clinical areas, such as oncology, saw an increase. For groups that received funding in 2022, the median proportion of income derived from industry was 2.2% (IQR, 0.3%–9.3%) and nine groups had over half their income from industry.ConclusionsIndustry funding of patient groups was widespread but skewed towards a small subset of groups and clinical areas. This may shift the focus of advocacy efforts towards certain conditions that align with current industry interests. Although further research is still needed on links between funding and patient group priorities, current disclosure measures may be insufficient to manage risks and access to other funding sources and additional safeguards may be needed to maintain independence.
Ashleigh Hooimeyer, Annim Mohammad, Alice Fabbri, Lisa Parker, Kellia Chiu, Barbara Mintzes
Costs of Delivering the Hep B PAST Model of Care in Remote Australia: A Retrospective Pre–Post Study
Objectives To estimate the direct medical costs of the Hep B Partnership Program (Hep B PAST) model of care compared with chronic hepatitis B (CHB) usual care from the health system perspective (Northern Territory (NT) Department of Health and the Commonwealth).Study TypeRetrospective cohort study (2014–2023) that linked primary care with inpatient, emergency, outpatient and outreach datasets. Costs were applied using National Weighted Activity Units, the Pharmaceutical Benefits Scheme and NT Government costings. A pre- and post-implementation design from a health system perspective was applied, with costs in 2023 Australian dollars.SettingRemote communities in the NT, Australia.ParticipantsThe cohort included all First Nations people living with CHB who were attending a clinic in a remote community that had consented to the Hep B PAST program, and who received care between 1 July 2014 and 31 May 2023.Main Outcome MeasuresAnnual mean and median healthcare costs per contact and per individual across service types, with comparisons of annual mean costs per individual between pre- and post-Hep B PAST using partially overlapping t-tests.ResultsAmong 1063 First Nations individuals with CHB, annual median costs per individual were similar for usual care ($639 [interquartile range, $366–1156]) and Hep B PAST ($770 [interquartile range, $400–1272]); mean costs were also similar for usual care versus Hep B PAST ($1701 vs. $1970; p = 0.12). By service type, annual median costs were similar for inpatient services ($7777 vs. $7795), primary care ($327 vs. $302) and outpatient visits ($1985 vs. $1858), and higher for Hep B PAST for emergency services ($1339 vs. $1672) and outreach care ($373 vs. $746).ConclusionsIn remote First Nations communities, Hep B PAST was delivered with a modest increase in direct medical costs compared with usual care. These findings can be used to inform future cost-effective evaluations. Future cost savings from decreased hepatocellular carcinoma and liver failure were not included.
Hoa Nguyen, Anh Le Tuan Nguyen, Paula Binks, Melita McKinnon, Emily Vintour-Cesar, Karen Wills, Nicola Stephens, Benjamin Cowie, Joshua S. Davis, Yuejen Zhao, Peter Nihill, Julie A. Campbell, Andrew J. Palmer, Jane Davies, Barbara de Graaff
Mending the Road: A Way Forward From Silence and Silencing
To the Editor, Thurtle's timely article [1] is one of a sea of examples where the default position of many of our healthcare bodies is captured very aptly by the Lancet article title: ‘Gaza has been failed by silence and impunity’ [2]. Both articles make for challenging reading, demonstrating how even pathways to publication have created their own form of denial and distance....
Ayman Hamdan, Anisa J. N. Jafar
Unlocking the Potential of Virtual Care in Australian Outpatient Services
Virtual care has become a critical component of contemporary health system reform, offering opportunities to improve access, continuity and efficiency of care. Virtual care is particularly relevant for chronic disease management, as it can support more continuous, coordinated and person-centred models of care. This commentary draws on evidence from a national project titled Smarter Hospitals and examines trends in virtual care use across four service areas (cancer, renal disease, mental health or conditions requiring rehabilitation) over 2019–2024, as well as key factors shaping virtual care use and opportunities to realise its full potential.
Ramya Walsan, Rebecca Mitchell, Karol Petrovska, Tracey Webster, Reema Harrison
Advancing Gender Equality in Australian Healthcare Leadership: Why National Targets Matter and What It Means for Healthcare Employers
Women comprise the majority of Australia's healthcare workforce yet remain underrepresented in leadership. This structural inequity has direct consequences for workforce sustainability and patient outcomes. Australia's new gender equality target-setting requirements, which create binding obligations for large employers, including major healthcare services, offer a timely mechanism to address this structural inequity. In this article, we explain why gender equality targets matter for healthcare, outline who must comply and what is required and describe how health services and training settings can embed targets within governance, clinical accountability and workforce systems. We introduce the Monash Learning Health System Maturity Matrix as a practical tool for aligning targets with organisational maturity and argue that, when implemented well, gender equality targets go beyond compliance, building the institutional resilience and culture that retains talent and delivers better care.
Belinda Garth, Nicole Pope, Jenny Proimos, Helena J. Teede
Centring Aboriginal and Torres Strait Islander Voices: A Framework for Culturally Safe and Racism-Free Healthcare
Culturally safe, racism-free healthcare is essential in Australia, yet Aboriginal and Torres Strait Islander people continue to face inequitable access, experiences and outcomes. Although cultural safety is widely cited, implementation remains shallow and disconnected from patients' realities. We argue that meaningful cultural safety requires Aboriginal and Torres Strait Islander governance, robust measurement and institutional accountability. Evidence shows that culturally unsafe care, including racism, creates psychological distress, leads to care avoidance and results in poorer outcomes, whereas Indigenous-led models perform considerably better. We propose a framework to strengthen cultural safety through Aboriginal and Torres Strait Islander community-governed assessment, greater accountability, data sovereignty and mandated cultural safety and anti-racism standards.
Elissa Elvidge, Roianne West, Karen Nicholls, Kiara Harvey, Yeena Thompson, Geraint B. Rogers, Yin Paradies
The AUstralian-CLimate and Health Attitudes, RIsk and Trust in the sYstem (AU-CLARITY) Study: A National, Representative Survey
Objectives Climate change, associated with heat spikes, floods, wildfires and changing patterns of vector-borne diseases, is a major determinant of health, and health system functioning. Understanding public perceptions of climate-related health risks and system preparedness can support equitable policy responses and effective health messaging.Study TypeCross-sectional.SettingOnline survey from 20 June to 27 August 2025.Participants6030 adults, aged ≥ 18 years, broadly representative of the Australian population.Main Outcome MeasuresThe AUstralian-CLimate and Health Attitudes, RIsk and Trust in the sYstem (AU-CLARITY) survey collected data on demographics, health status, experiences of climate-related events, and views on climate change and health system preparedness.ResultsRespondents (65%, 3910/6030) were concerned about climate change, yet only 45% (2735/6030) perceived it as a serious risk to their own health. Personal risk perception declined with age (odds ratio [OR] = 0.98; 95% confidence interval [CI], 0.98–0.98) and was higher among females (OR = 1.28; 95% CI, 1.15–1.43), First Nations people (OR = 1.44; 95% CI, 1.22–1.71), multilingual individuals (OR = 1.44; 95% CI, 1.22–1.71) and those with higher education (OR = 1.28; 95% CI, 1.12–1.46). Personal experience of a climate-related event increased perceived risk (OR = 1.97; 95% CI, 1.73–2.24). Regional and remote residents were less likely to perceive health risk (OR = 0.76; 95% CI, 0.65–0.89). A third (37%; 2209/6030) of respondents believed that the healthcare system was prepared for climate change. Being female (OR = 2.35; 95% CI, 2.10–2.65), having a chronic condition (OR = 1.47; 95% CI, 1.28–1.68) and older age (OR = 1.01; 95% CI, 1.01–1.01) increased perceptions that the system was unprepared. Those with higher education, who had been personally impacted, or identified as First Nations had more confidence in the system's preparedness.ConclusionsMany Australians recognise climate change as a health challenge; personal risk perception and confidence in system preparedness vary. Targeted health policies are needed to effectively communicate health risks and support healthcare's climate change resilience.
Jeffrey Braithwaite, Carolynn L. Smith, Yvonne A. Zurynski, Louise A. Ellis, Georgia Fisher, Kate Churruca, Lisa Pagano, Samantha Spanos, Janet C. Long, Christina Rojas, S. Bruce Dowton
Rapid Growth in Diagnostic CT Knee Imaging in Australia: Implications for Imaging Stewardship
Computed tomography (CT) of the knee has traditionally had a limited role in routine practice. Recent Medicare data show a rapid increase in CT knee utilisation in Australia, far exceeding growth in other imaging modalities. This divergence is unlikely to reflect clinical need and instead suggests a shift in practice, potentially driven by expansion into non-evidence-based CT-guided procedures. This raises concerns regarding unnecessary radiation exposure, procedure-related harm and escalating costs driven by volume rather than value. The absence of clear differentiation between diagnostic and procedural CT imaging within current Medicare Benefits Schedule item structures limits oversight. Imaging stewardship and policy reform are required to ensure appropriate, evidence-based use.
Hanwen Chen, Rachelle Buchbinder, Sean Docking, Ian A Harris
The Changing Indications for Adult Liver Transplantation in Australia: A Narrative Review
Adult liver transplantation practice in Australia and New Zealand has changed substantially over the past decade in response to shifting liver disease epidemiology and advances in donor organ preservation. Alcohol-related liver disease and metabolic dysfunction-associated steatotic liver disease have become leading indications for adult liver transplantation in Australia and New Zealand. Transplant recipients are increasingly older and medically complex, necessitating multi-disciplinary assessment including evaluation of frailty. Indications for liver transplantation have expanded to include selected patients with severe alcohol-related hepatitis, acute-on-chronic liver failure, extended-criteria hepatocellular carcinoma and other highly selected non-resectable liver malignancies including colorectal liver metastases and cholangiocarcinoma. In parallel, donor utilisation has evolved, with increasing use of expanded-criteria donors and donation after circulatory determination of death. Machine perfusion technologies are increasingly used in Australia to optimise marginal liver grafts and minimise waitlist mortality. Having an awareness of these evolving indications, recipient complexity and donor optimisation strategies is essential to support timely liver transplantation referral, improve inter-disciplinary understanding, allow equitable access and provide appropriate stewardship of limited donor organs.
Fadak Mohammadi, Alan J. Wigg, Ken Liu, Simone I. Strasser
Unshrouding Social Determinants: A Case for Standardised Data in Australia's Health Information Ecosystem
Australia's health information system captures clinical and administrative data with precision but overlooks social determinants of health (SDoH), such as housing and education. This deficiency limits predictive accuracy of clinical and economic models and perpetuates health inequities. Despite significant investment in digital health reforms, Australia's current strategies for data interoperability lack SDoH standards. Drawing on international benchmarks, Australia should pursue a national framework to integrate standardised SDoH measures into electronic health records. Collaborative adoption via a phased approach focused on data sovereignty, interoperability and ethical AI governance has the potential to transform Australia's healthcare into a more person-centred, equitable system.
Christopher Ryan, Christine T. Shiner, Rebecca J. Harris, Carrie Lethborg, Vijaya Sundararajan
Roadmap to Support International Medical Graduates for Satisfying Rural General Practice Careers: A Realist Evaluation Approach
Objectives Develop a roadmap of contextualised strategies to support international medical graduates (IMGs) on the pathway into satisfying rural general practitioner careers in Australia.DesignRealist evaluation approach.Setting, ParticipantsOnline semi-structured interviews, focus groups and intermittent feedback cycles developed, refined and confirmed a contextualised roadmap of strategies between 1 November 2024 and 27 July 2025. Participants were purposefully selected for IMG background and different pathways into rural general practice careers across Australia. This included a 10-person project advisory group and 31 external participants covering decision-makers, training teams, supervisors and trainees. Questions explored practical strategies to drive comfort, confidence, competence, belonging and bonding.Main Outcome MeasuresContextualised strategies for IMGs to achieve satisfying rural general practice careers.ResultsThe roadmap identified that when migrating and acclimatising, providing IMGs with centralised resources and information on rural general practice training and careers promotes comfort and empowerment. When moving to new workplaces and communities, providing IMGs with supportive workplaces for early supervised practice, skill bridging and opportunities to connect with other doctors', families and communities stimulates IMG confidence, competence and sense of community belonging. When training to become a general practitioner rurally, providing IMGs with family-focused, equitable training matched to the IMG and the community, and training that builds on IMG capabilities, promotes a sense of professional belonging and bonding. We identified that early intervention and a continuity of supports are important for more comprehensively supported IMGs.ConclusionsOngoing timely support, when multi-layered, tailored and integrated, may assist IMGs to gain specialist general practice qualifications, feel valued and to settle in rural general practice roles. The roadmap provides a basis for planning coordinated longitudinal support by distributed agencies.
Belinda G. O'Sullivan, Kim J. Omond, Neysan Sedaghat
Still Treating Yesterday's Risk? Reconsidering Antiviral Use for Mild-to-Moderate COVID-19 Cases in a Broadly Immune Population
Antivirals for mild-to-moderate coronavirus disease 2019 (COVID-19) were adopted for use based on trials in unvaccinated adults during the pre-Omicron period. In today's broadly immune populations, where the risk of hospitalisation and death has decreased substantially, there is a lack of high-quality contemporary evidence to support routine antiviral use for mild-to-moderate disease. Comparing the Australian and New Zealand experiences in the evolving COVID-19 landscape highlights differences in policy and prescribing practice. Treatment guidelines should be informed by systematic evaluation of emerging data, given uncertainty regarding antiviral effectiveness in a context of widespread immunity and milder disease, which have altered the balance of risks and benefits.
Hadar Mudrik-Zohar, Tim Cutfield, Susan Morpeth, Thomas Hills, Eamon Duffy, Laura J. Edwards, Allen C. Cheng, Steven Y. C. Tong
Curating an evidence base for health research and policy making: more crucial than ever
The end of the year is a good time to reflect on why a journal like the MJA does what it does, who supports the Journal's work, and the headwinds that journals are navigating. The MJA publishes high quality research and commentary that aims to inform health policy and influence medical practice in Australia. Our process is largely one of curation of what is submitted to us, combined with commissioning on issues we identify as important. We prioritise for publication articles that report on or discuss conditions with a high burden of disease, that are likely to have an effect on policy or practice, support Aboriginal and Torres Strait Islander health and wellbeing, and articles that report on uniquely Australian topics. Articles go through a rigorous process that includes editorial assessment, peer review, author revision in response to peer review, and, after acceptance, expert structural editing. We hope that this process — essentially a collaboration between authors, editors and reviewers — will ensure that, by the time an article is published, it is the best representation of the authors’ work. In the 12 months to 31 October 2024, the MJA received 1598 articles, of which 196 were accepted; we publish around 10–12 in each issue. Each issue is a curated mix of content; some, such as the theme issues on surgery (https://www.mja.com.au/journal/2024/220/5), general practice (https://www.mja.com.au/journal/2024/220/9), women's health (https://www.mja.com.au/journal/2024/221/7), infectious diseases (https://www.mja.com.au/journal/2024/221/4), child and adolescent health (https://www.mja.com.au/journal/2024/221/10), and the special issue on Indigenous health (https://www.mja.com.au/journal/2024/221/1), have a specific focus. This end of year issue has no specific theme; its diversity, however, collectively reflects the Journal's priorities. We hope these articles will interest you as readers and support you in your clinical practice or research as much as we were fascinated by them as editors. The research articles include an analysis of the cost of treating hypertension (https://doi.org/10.5694/mja2.52522), participation in the national bowel screening program by people with severe mental illness (https://doi.org/10.5694/mja2.52521), an analysis of out‐of‐hospital cardiac arrests (https://doi.org/10.5694/mja2.52532), and an analysis of the Northern Territory health workforce (https://doi.org/10.5694/mja2.52507). Perspectives include the need for targeted prevention and treatment of stroke in young women (https://doi.org/10.5694/mja2.52516), and a review of the evidence of persistently replicating SARS‐CoV‐2 as a driver of long COVID (https://doi.org/10.5694/mja2.52517). We are proud to also publish in this section a thoughtful article, “Decolonisation, Indigenous health research, and Indigenous authorship: sharing our teams’ principles and practices” (https://doi.org/10.5694/mja2.52509), by a collective of Aboriginal and non‐Indigenous researchers, who work together in two Aboriginal‐led research teams. In the decisions we make at the MJA, we are supported on a daily basis by many reviewers who give their time and expertise to help us provide what we think is an essential service: high quality evidence‐based research and commentary to support decision making in health care. In the past 12 months, they submitted between them 855 reviews. We provide below a list of the reviewers who have reviewed for us in the past 12 months and we are grateful to all of them for what they do to support the MJA. We are also very grateful to the members of our Editorial Advisory Group, who provide ongoing expert advice. This year we are especially grateful to the Guest Editors for the July special issue on Indigenous health that we published in association with the Lowitja Institute (https://www.mja.com.au/journal/2024/221/1). Their work in curating this special issue is one that we were very proud to support as part of the MJA's ongoing commitment to excellence and leadership in Aboriginal and Torres Strait Islander led health research. In 2024, more than 100 countries, representing about half of the world's population, have had the chance to vote in regional, national or local elections. Perhaps, more than ever before, the evidence base for science and medicine have been on the ballot and it is not clear that it has been on the winning side in every case. In reflecting back on what we do, the role of peer‐reviewed journals such as the MJA will be even more crucial over the next few years in helping navigate the vast amount of medical information that exists. We are very grateful for everyone that supports the work that we do at the MJA, and who does work themselves in evidence‐based health research and policy making. Now, more than ever, this work is crucial to support a functioning and evidence‐informed society. The MJA Editorial Advisory Group, November 2024 The MJA Editorial Advisory Group members are eminent clinicians and scholars who are valuable sources of ideas for the content of the Journal. They provide constructive criticism of the format and content of the Journal, and provide independent advice to the MJA Editorial Committee on appeals of editorial decisions, problematic articles, and complaints about the editorial process. John Attia Lilon G Bandler Anthony Capon Flavia M Cicuttini Paul B Colditz Brendan S Crabb Jaya Dantas Anne Duggan David A Ellwood Alex Farrell Peter G Gibson Marc Gladman Charles Guest Claire L Jackson Cheryl A Jones Zsuzsoka Kecskes José Florencio Fabella Lapeña, Jr Christopher Levi C Raina MacIntyre Jennifer Martin Patrick D McGorry Catriona McLean Lucy Morgan Peter L Munk Debra Nestel Ian N Olver Wilfred Peh Anna Ralph Toby Richards Christobel Saunders Susan Sawyer Jeong‐Wook Seo Lambert W Schuwirth Joseph Sung Helena Teede Philip G Truskett Robyn Ward Steve Wesselingh Paul S Worley Catherine Yelland Neville D Yeomans Jeffrey Zajac MJA reviewers, 31 October 2023 – 1 November 2024 Jason Abbott Lisa M Abbott Karen Adams Oyelola Adegboye Barbara‐Ann Adelstein Stephen Adelstein Hossein Adibi John Adie Susannah Ahern Chris Alderman Sarah Ali Nicole L Allard Penny L Allen Janaki Amin David John Amor Craig S Anderson Robert Anderson Catarina Ang Nigel R Armfield Amit Arora Kingsley Asiedu Deborah A Askew Eugene Athan John J Atherton David N Atkinson John R Attia Oyekoya Taiwo Ayonrinde Leon A Bach Kathryn Backholer Tony Badrick Michael Baigent Jannine Bailey Suzanne Bain‐Donohue Ross I Baker Eileen Baldry Zoe Baldwin Lilon G Bandler Bridget Barber Ruth A Barker Kristine Kay Barlow‐Stewart Rahul D Barmanray Amanda Barnard Adrian G Barnett Dylan Dominic Barth Tarun Bastiampillai Marijka Batterham Malcolm W Battersby Frank H Beard Kenneth Beath Lorri Beatty Paul J Beggs Justin Beilby Katy JL Bell Scott C Bell Simon Bell Derrick A Bennett Julie Bennett Jill Benson Stephanie Best Neera Bhatia Laurent Billot Justin Bilszta Marie M Bismark Habtamu Bizuayehu Deborah A Black J Andrew Black Kirsten I Black Christopher F Bladin Tony Blakely Paul Blaschke Melissa Jane Bloomer Peter Boan Angie Bone Michael A Bonning Kade Booth Jeffrey Boris Jessica Botfield Eric Bouffet Mark Boughey Lisa Bourke Asha C Bowen Simon D Bowler Annette J Braunack‐Mayer Ruanne Brell Bruce J Brew Fraser J Brims Peter J Bristow Julia M L Brotherton Anthony James Brown Katharine Brown Claudia Bruno Jamie Bryant David J Buckley Liz Buckley Nicholas A Buckley T Jared Bunch Hayden Burch Luke Burchill Sally A Burrows Jane A Buxton Oyungerel Byambasuren Gerard J Byrne Dominique A Cadilhac Rosemary Calder Emily Joy Callander Ian D Cameron Peter A Cameron Anna Campain David G Campbell Lewis Campbell Ben J Canny Karla J Canuto Cheryl Carcel Phillip J Carson Judith Cashmore Gillian E Caughey Elena Cavazzoni Blake S Cavve Steven J Chadban Leanne Chalmers Sonia Chanchlani Manju Chandrasegaram Jenny Chang Jack Chen Bernard Man Yung Cheung Derek P Chew Angela L Chiew HuiJun Chih Philip MC Choi Stephanie KY Choi Clara K Chow Eric P F Chow Intifar Chowdhury Kate Churruca Tainya Clarke David Coghill Neale D Cohen Paul B Colditz Catherine Coleborne Jacinta M Coleman Samantha Colledge‐Frisby Alex Collie Peter J Collignon Philippa Collin Josielli Comachio Robert James Commons Luke B Connelly Mark S Cooper Matt Cooper Michael D Coory Vincent J Cornelisse Colin Hilton Cortie Christopher Coulter Sean Cowlishaw Stephen Cox Terry J Coyne Simon Craig Susanna Cramb Gregory Crawford Julia L Crilly Philip Crispin Simon R Crouch Andrew Crowden Mark Crowther Alana R Cuthbert Mark Daglish Eleonora Dal Grande Kathryn Daley Carlton D Dampier Benjamin Daniels Jaya A R Dantas Jai N Darvall Mike Daube A James M Daveson Stephanie J Davies Ian D Davis Joshua S Davis Stephanie Davis Susan R Davis Angela Dawson Carolyn A Day John F de Campo Caroline M de Costa Barbara de Graaff Bouke de Jong Anthony Dear Katrine Del Villar Anthony Delaney Clare Delany Sarah M Dennis Jane Desborough John A Devereux Haryana M Dhillon Terrence H Diamond Hugh G Dickson Christianna Digenis Joanna Dipnall George Disney Loc Giang Do Annette J Dobson Jodie M Dodd Xenia Dolja‐Gore Susan M Donath Katina D'Onise Paul J Douglas Jenny A Doust James Dowty Andrea Driscoll Olaf H Drummer Stephen J Duckett Johan A Duflou Pascal Duijf Gregory J Duncombe Karen Maree Dwyer John R Dyer Diana Egerton‐Warburton John W Eikelboom Robert H Eikelboom Paul Eleftheriou David H Ellis Pete M Ellis David A Ellwood Elissa Elvidge Jon D Emery Guy D Eslick David Espinoza Mohamed Estai Claudia Estcourt Sue M Evans Christopher K Fairley Kristy Fakes Michael O Falster Jonathon P Fanning Jillann F Farmer Michael Farrell Daniel M Fatovich Stuart Faulkner Jane Christine Fazio Deirdre Fetherstonhaugh David W Firman Matt Fisher Robert A Fitridge Gerard J FitzGerald John L Fitzgerald Arthas Flabouris Stephen C Flecknoe‐Brown John I Fleming Darran Foo Malcolm Forbes Kevin D Forsyth David Fraile Navarro Peter Franklin John K French Frank A Frizelle Lara Fuller Clara Gaff Nicholas Gall Seana Gall Edward J Gane Lydia Garside Coral E Gartner Gail Garvey Madlen Gazarian Alison Gibberd Nathan J Gibbs Peter G Gibson Peter R Gibson Gerard Francis Gill Stephen Dean Gill Lynn H Gillam Allan R Glanville Rebecca Glauert Stacy K Goergen Day Way Goh Lisa Gold Rimma Goldberg Matthew R Golden David E Goldsbury Judith Gomersall Phillip D Good Belinda Goodwin Alexandra S Gorelik Rebekah Grace Patricia Graves Melissa J Green Suetonia Green Tim J Green Jerry R Greenfield Trisha Greenhalgh Jennene Greenhill Jessica A Grieger Sonia R Grover Luke E Grzeskowiak Eric Guazzo Pascale Guitera Hasantha Gunasekera Monisha Gupta Lyle C Gurrin Thi Ninh Ha Dandara Haag Bronwyn B Haasdyk Mohsen Habibian Penny Hagen Sally Hall Dykgraaf Christian R Hamilton‐Craig Mark J Hanly Isabel Hanson Damian Harding Stephen Harfield David Harley Benjamin Harrap Ian A Harris Katie Harris Mark F Harris Jo Harrison Simon J Harrison Stephanie Harrison Roger J Hart Gunter F Hartel Mary Anne Hartley Lara Harvey Rubayyat Hashmi Alys Havard Andrew Hayen Christopher Hayes Richard B Hays Christopher H Heath Geoffrey S Hebbard Michael A Henderson Martin Hensher Subash Shanthakumar Heraganahally Ana Herceg Helen E Herrman Charlotte Mary Hespe Martha Hickey Peter Higgs Joanna Hikaka Andrew G Hill David R Hillman Kenneth M Hillman Sarah N Hilmer Dana A Hince Pravin Hissaria Danielle Hitch Peter G Hobbins Alberta Hoi Michael J Hollands Caroline SE Homer Preben Homoe Thai Phuoc Hong Gary Hooper John Hopper John D Horowitz Robert L Horvath Elizabeth D Hotham Paul Hotton Nehmat Houssami Jessica Howell Martin Howell Wendy Hu Catherine E Huggins Jaquelyne Hughes Lisa Hui Rod W Hunt Roger W Hunt Arnagretta Hunter Jennifer Hunter Peter C Hunter Elizabeth Hurrion Sarah J Hyde Zoë Hyde Jonathan A Hyett Susan Ieraci Maria C Inacio Warrick J Inder Joan Ingram Geoffrey K Isbister Katherine Z Isoardi Rowena G Ivers Christopher Jackson Claire L Jackson Melinda Jackson Theresa Jacques Farzana Jahan Sharon James Stacey K Jankelowitz Edward D Janus Edward Jegasothy Charles G Jenkinson Awachana Jiamsakul Liza Johannesson Sarah Johnson Brian D Johnston Alexandra Jones Michael P Jones Scott Jones Michelle Jongenelis Robert N Jorissen Matthew D Jose Joanne Joseph Preeti Avinash Joshi Manjul Joshipura Craig Phillip Juergens Nadarajah Kangaharan Jonathan Karnon Judith M Katzenellenbogen Margaret P Kay Karuna Keat Damien Kee June Keeling Michelle Kehoe Nicholas A Keks Justin Kenardy Debra S Kennedy Emma Kennedy Michelle Kennedy Suzanne Kennewell Danelle Kenny Katherine Kenny Dev A S Kevat Ehsan Khan Karen Kiang Ganessan Kichenadasse Hansoo Kim Joosup Kim Michael G Kimlin Lara Anne Kimmel Jeffrey Klausner Christopher S Kneebone Taryn Knox Jonathan Koea Pamela Konecny Kelvin M Kong Viola Korczak Zeff Koutsogiannis Leonard Kritharides Estie Kruger Eeva‐Katri Kumpula Ronald Labonte Luise Patricia Lago Vinay Lakra Stephen B Lambert Riki Lane Aleksandra Lange Alexander Larcombe Michael Larkin Sarah L Larkins Anne‐Marie Laslett Zohra Lassi Dennis Lau Namson Shon Chung Lau Kate Laver David M Lawrence Minh Le Cong Bernard Arnaud Leckning Karin Leder Adriene Lee James C Lee Stephen R Leeder Amy Legg James W Leitch Christopher N Lemoh Peter J Lewindon Xia Li Xue (Snow) Li Winston Spencer Liauw Michael Libman Leanne Liddle Susan Liew Vidya S Limaye Ivan Lin Anthea Lindquist Daniel Lindsay Damien Linnane Clare Littleton Dan Liu Andrew R Lloyd Serigne Lo David Long Derrick Lopez Susan M Lord Paula Lorgelly Jeanne Louw Michaela Lucas Guy L Ludbrook Sanja Lujic Ronald Ma Gustavo Machado Andrew I MacIsaac Heather G Mack John S Mackenzie Rona Macniven Richard Cawley Madden Guy J Maddern Parker John Magin Farah Magrabi Karen Magraith Robert Mahar Colin J Mahoney David Majewski Ashanya Malalasekera Allison Malcolm Arunima Malik James Leslie Mallows Linda Mann Jo‐Anne Elizabeth Manski‐Nankervis Danielle Manton Victoria J Mar Ben J Marais Tania P Markovic Susan Marks Nathaniel S Marshall Jennifer H Martin Kaka Martina Marianne Martinello Thomas H Marwick Lester Mascarenhas Siobhán Masterson Heather Mattner Richard Matzopoulos Danielle Mazza Scott McAlister Sally M McCarthy Peter McCluskey Stephen P McDonald Alison McEwen Forbes McGain Julie McGaughran Richard G McGee Peter McGeorge Steven McGloughlin Matthew Richard McGrail Iain McGregor Peter B McIntyre Andrea McKivett Donald McLeod Brendan McMullan Danielle McMullen Kathleen McNamee Ryan Mead‐Hunter Graham N Meadows Niamh Meagher Jacqueline K Mein Tracy Lee Merlin William J Milford Jeremy L Millar Robert Miller Llew Mills Rachel Milte Alyssa Milton Gita D Mishra David James Mitchell Geoffrey K Mitchell Francis Mitrou Michael Montalto Julia K Moore Michael J Moore Robyn Moore Philip Morgan Susan J Morgan Peter Morley Jedidiah Morton Robert G Moses Robert F W Moulds David Mountain Alison M Mudge James Muir Zachary Munn Cammi Murrup‐Stewart Danielle Muscat Vasi Naganathan Balakrishnan (Kichu) R Nair Sanjay Nandurkar Alison J Nankervis Natasha Nassar Merrilee Needham Amanda Louise Neil Mark R Nelson David A Newby Evan D Newnham John Newnham Yee Ching Ng Sam Ngan Son H Nghiem Danielle Ni Chroinin Gary Nicholls Suzanne Nielsen Rosemary L Nixon Antony Nocera Alicia Norman Robert Norton Vicki O'Donnell Patrick Oakley Jeremy J N Oats James O'beirne Carly Oboudiyat Penny O'Brien Anne O'Connor Daniel Bogale Odo Nicholas J Osborne Joshua Osowicki Jessica Pace Ellie Paige Andrew John Palmer Adriana Parrella Carmen Parter Nalini Pati Sue Pavord Christopher Pearce Odette Pearson Roxanna Pebdani Carmelle Peisah Yang Peng Jonathan Penm Charana Perera Gregory M Peterson Naomi Pfitzner Richard K S Phoon Robert W Pickles S Praga Pillay Dino Pisaniello Sabrina W Pit Michael Pollanen James Pollard C Dimity Pond Phillippa J Poole Michelle Porter Christopher John Poulos Jeffrey Presneill Karen Price Jenny Proimos Susanna Margaret Proudman Mark Putland Rennie Qin Helen E Quinn Steve Quinn Miia Rahja Eamon P Raith Satish Raj Anna P Ralph Geetha Ranmuthugala Jonas Ranstam Melissa Raven Jennifer S Reath Helen K Reddel Stephen Reddel Susan J Rees Christopher Reid Ian R Reid Joel Rhee Alice M Richardson Drew B Richardson Damien Riggs Malcolm D Riley Ian T Ring Marco Rizzi Vijay Roach Fiona Robards Kathryn Victoria Roberts Chris Robertson Iain K Robertson Paul G Robertson Jo Robinson Kerry Robinson Jenny M Robson Leigh Roeger Benjmain Rogers Margaret J Rogers Loreto Vanessa Tevah Rose Jacqueline Roseleur Sebastian P Rosenberg Andrew Ross Bronwen Ross Glynis P Ross Stacey L Rowe Bosco Rowland Amanda Roxburgh Darren B Russell Fiona Russell Courtney Ryder Bandana Saini Jonathan M Samet Mina Sarofim Sarah Sasson Christobel M Saunders John Saunders Rebecca B Saunderson Feby Savira Andrea L Schaffer Chris Schilling Markus Schlaich Violeta Schubert Tim Schultz Kate Scoles James G Scott Paul A Scuffham Holly Seale Deshan F Sebaratnam Paul J Secombe Rhiann Sue See Marie‐Claire Seeley Leonie Segal Tarun Sen Gupta Sanjaya N Senanayake Stefan Serban Hannah Seymour Anthony Shakeshaft Shokoofeh Shamsi Rashmi Sharma Md Shajedur Rahman Shawon Dinberu Shebeshi Daisy Shepherd Heather Shepherd Kirsty Short Alexis Leah Shub William Sievert Kyra Sim David Simmons Andrew H Singer Leda Sivak Dana Rose Marie Louise Slape Janet K Sluggett David P Smith Jane Smith Hayley Smithers‐Sheedy Jennifer Smith‐Merry Thomas L Snelling Hayden A Snow Jessamine Soderstrom Tania C Sorrell Denis Spelman Alicia J Spittle Geoffrey K Spurling Preeyaporn Srasuebkul Ingrid Stacey Andrew Staib Julia Steinberg Alexandre S Stephens Michele Sterling Mark Stevenson Adam Stewart Rob Stirling Martin R Stockler Nigel P Stocks Simone I Strasser Edward Strivens Bronwyn Gwenneth Ann Stuckey Elizabeth Ann Sturgiss Wei‐May Su Takemi Sugiyama Ahna Ballonoff Suleiman Clair Sullivan Anastasia S Suraev Tatiana Surzhina Georgina Sutherland Tom Sutherland Aaron L Sverdlov Arianne Sweeting Prue Talbot Nicholas J Talley Natassia Pinpin Tan Patrick Tansley Avelina Tarrago Amanda Taylor Adam G Testro Hiran Thabrew Mark AB Thomas Alexander Thompson Kelly Thompson Tilda Nell Thomson Karen Thorpe Matthew Tieu Kaylie Toll Shidan Tosif Stephen Craig Trumble Haitham Tuffafa Thomas Turnbull Stuart Turville Bep Uink Patricia C Valery Kees van Gool Leesa Van Niekerk Alicia Veasey Mark George Knox Veitch Rebecca Louise Venchiarutti Bala Venkatesh Deborah Verran Karin Verspoor Elmer V Villanueva Renuka Visvanathan Beverley Vollenhoven Amy Von Huben Kylie Vuong Zoe Wainer Dennis Walker Robert J Walker Richard Walton Michael B Ward Peter A B Wark David D Warrell Chelsea J Watego David I Watson Jared Watts Cora Weber‐Pillwax Peter Wein Barbara Weinstein Heidi Welberry Cameron Wells Aliza Werner‐Seidler Robb Wesselingh Juanita L Westbury Seth Westhead Melissa Anne Wheeler Sara Whitburn Cassandra White Christopher P White Jenni White Julian White Kate White David C Whiteman Alan John Wigg Kay A Wilhelm Garry J Wilkes Chris S Wilkinson Dominic J C Wilkinson Louise Wilkinson Carmel Williams Craig Williams Crystal Williams Megan Williams Robyn Williams Andrew Wilson Leon Winata Ingrid Winship Sarah Wise Gary A Wittert Vincent Wing Ming Wong Anna Wood Michael C Woodward AM Paul Worley Melina Gattellari Worthington Michael Wright Ian Wronski Rosemary Wyber Elizabeth J Wylie Jessica Yang Mark W Yates Margaret R Zacharin Ehud Zamir Christopher Zeitz Yuejen Zhao Nicholas A Zwar
Virginia Barbour
Policy influential research: setting, informing and decoding our national health and social policy agenda and activities
The MJA aims to prioritise studies that will “advance knowledge or practice with respect to medical problems of significance for Australia”. This is particularly inclusive of studies that not only have the potential to affect clinical practice, but also to help set, inform and improve our national health and social policies. In this issue of the MJA, we showcase several studies that have and will continue to inform national policy, help us understand how evidence can be used to best effect in the health policy process, and remind us of how and what is being done about other important national policy priorities. Australia's journey in regulating vaping, a relatively recent yet significant public health threat, especially to younger people, has taken a positive turn this year. The Therapeutic Goods and Other Legislation Amendment (Vaping Reforms) Act 2024 took effect in July 2024 and significant more regulation to access, packaging, and formulations of vapes was introduced nationally (https://www.aph.gov.au/Parliamentary_Business/Bills_Legislation/bd/bd2324a/24bd061a). These changes are internationally recognised as bold attempts at curbing vaping among younger people and have been influenced by an enormous body of work and advocacy. It is work such as Jenkins and colleagues’ (https://doi.org/10.5694/mja2.52423) in this issue, which identified a synthetic nicotine analogue (6‐methylnicotine) in “non‐nicotine” vapes and accompanying inconsistent chemical reporting, that are the pillars of evidence required to inform our national legislative journey. As noted by Larcombe and Hunter (https://doi.org/10.5694/mja2.52422) in an accompanying editorial, loopholes in legislation will continue to be used by vape manufacturers and our regulatory bodies must keep up, or ideally get in front of their attempts at circumventing them using evidence like that presented by Jenkins and colleagues. This issue of the MJA also includes a compendium piece for readers of modelled economic evaluations by Chen and colleagues (https://doi.org/10.5694/mja2.52409). Economic evaluations are ubiquitous and critical to how Australia makes decisions about medicines, devices, and other health care services (https://www.sciencedirect.com/science/article/pii/S221210992030666X), yet not always clearly accessible to non‐health economist readers. Chen et al remind us that with more complex questions, interventions, heterogenous populations, and luckily more computational power, more sophisticated model‐based economic evaluations are required, unavoidable, and our understanding of them must evolve. Using two recent MJA studies as examples (https://doi.org/10.5694/mja2.51825, https://doi.org/10.5694/mja2.51860), Chen et al describe how model‐based evaluations compare to study‐based evaluation, major modelling choices with powerful visual representations of these models and advice on what to look out for when determining model robustness. In Engel and Mihalopoulos’ perspective (https://doi.org/10.5694/mja2.52414), we read about loneliness and its economic impact, an area of increasing national recognition and evolving health and social policies. Loneliness, affecting almost one‐third of adults over 60 years of age and two‐thirds of older adults living in residential care, needs cost‐effective national strategies. Although a bidirectional relationship between loneliness and chronic health problems is not surprising, the magnitude of its potential health effects (eg, 26% higher risk of death), and the increasingly obvious impact that it has on our health system ($2.7 billion annually) that Engel and Mihalopoulos cite is alarming. However, it is not all doom and gloom. Engel and Mihalopoulos suggest that research has identified some critical elements of successful loneliness intervention strategies, including holistic community‐based and ‐led health and social care, and several promising intervention types. Interestingly, one such proposed strategy to address loneliness is “social prescribing”, which Yadav and colleagues’ (https://doi.org/10.5694/mja2.52413) letter to the editor introduces as the “core business” of Aboriginal and Torres Strait Islander community‐controlled health organisations. Yadav et al's call to action that we should learn more from Indigenous models of social prescribing could not have come at a more pertinent time.
Maria Inacio
The impact of national policies and approaches on health and research
This issue of the MJA highlights areas where health and research can be affected — both positively and negatively — by national policies and approaches. Sexual and reproductive health are at a critical time globally with these rights under attack in so many places. Catriona Melville and Bonney Corbin highlight the areas where Australia has been “quietly making changes for the better” (doi: 10.5694/mja2.52194). These reforms are to be celebrated and are substantial. As they note, “we have seen more changes in the past six years than in the previous 60”. However, they pose critical questions on how these reforms can be protected and how can they be equitable. They conclude that although we are in the privileged position in Australia of no longer needing to noisily advocate for basic reproductive rights, “every one of us must reflect on our roles, responsibilities and power to reshape Australian health systems so that all people can choose if, how and when to parent”. Their message is reinforced in the editorial by Asvini Subasinghe and Seema Deb (doi: 10.5694/mja2.52210), who comment on two research articles on abortion in Victoria by Kristina Edvardsson and colleagues (doi: 10.5694/mja2.52202) and Melvin Marzan and colleagues (doi: 10.5694/mja2.52203). As their starting point, Subasinghe and Deb note the structural barriers to abortion care in Australia found by the 2023 Senate inquiry, and the lack of knowledge on equity of access. They note that “Support from peak bodies and the government for providing equitable access to early medical abortion has increased” but “much remains to be done to achieve equitable access for all Australian women”, and they make a case for a national abortion registry to support research into this area. The need for better research and coordination — this time for emerging therapies for children and adolescents — is the topic of a perspective by Michelle Lorentzos and colleagues (doi: 10.5694/mja2.52191). They highlight the need for collaboration and investment to ensure that children and adolescents access clinical trials and the many new therapies that are becoming available for diseases which have previously had few therapeutic options. The challenge with many of these diseases is their rarity, compounded in Australia by distance. The authors call for “the development of a national collaborative community of paediatric trials centres”, noting that “Given the rarity of many paediatric diseases and the complexity of emerging therapies, a national approach for complex trials in paediatrics is imperative”. They conclude that “without a change in approach to paediatric clinical trial delivery in Australia, paediatric clinical trials centres are at risk of failing to deliver equitable efficient access to novel treatment options”. Finally, a lesson from practice provides a timely reminder of an important infectious disease and the need for careful differential diagnosis and public health follow‐up. Caitlin Swift and colleagues describe a case of cutaneous diphtheria on the scalp of a man in conjunction with basal cell carcinoma (doi: 10.5694/mja2.52190). The case reinforces the importance of clinical vigilance and, for such an important disease, “prepared public health systems to enable a prompt response”. They conclude that “Maintaining high diphtheria vaccination coverage across all ages is crucial for protection against severe disease”.
Virginia Barbour
Out‐of‐pocket fees for health care in Australia: implications for equity
Out‐of‐pocket fees create access barriers to health care, exacerbating health inequalities In Australia, 15% of all expenditure on health care comes directly from individuals in the form of out‐of‐pocket fees — this is almost double the amount contributed by private health insurers.1 There is concern that vulnerable groups — socio‐economically disadvantaged people and older Australians in particular, who also have higher health care needs — are spending larger proportions of their incomes on out‐of‐pocket fees for health care.2 A 2019 study identified that one in three low income households are spending more than 10% of their income on health care.3 This might create economic hardship, and individuals do forgo care,4 with one in four Australians without a health care condition and up to one in two with certain health conditions avoiding care because of the cost.4 Health care services in Australia are delivered through a mixture of public and private providers, with governments subsidising the costs of care but out‐of‐pocket fees remaining a significant component.5 Australia is not unique in this, with similar systems in New Zealand, Ireland, France, Germany, the Netherlands, and the United Kingdom. However, in Australia, out‐of‐pocket fees make up a larger proportion of overall health expenditure than in these other countries.6 The amount paid by households on health care in Australia was estimated to be $3200 in 2014,3 with out‐of‐pocket fees per health care service rising over time.7 The increasing out‐of‐pocket expenditure by patients is concerning in light of international experience in the United States, where there is a reliance on private or market‐based health care, and health care costs are the leading cause of bankruptcy.8 The level of out‐of‐pocket fees in Australia has ignited vigorous policy and academic debate.9,10,11 Varied viewpoints range from the impact of high fees on a patient's ability to access care4 and the equity implications of high fees,12 to the right of private providers to set their own fees in an open market and to recover costs of providing care.13 Out‐of‐pocket fees are also part of cost‐sharing measures between governments and patients, as a result of increasing government expenditure on health care and unprecedented levels of demand.1 This article examines the current provision of health care and out‐of‐pocket fees within Australia through a micro‐economic lens, identifying the access and equity implications of the dual public–private system, and considers potential systems‐level options for a way forward. Universal health care and private health insurance in Australia Under Australia's universal health care system, individuals can access care in public hospitals free of charge. Public hospitals are owned and operated by state governments. Outside of public hospitals, health care services are owned and operated by private providers on either a for‐profit or not‐for‐profit basis. The costs to individuals for accessing these services are partly subsidised by the federal government through Medicare. Medicare covers services such as consultations with general practitioners and specialists, and diagnostic tests and imaging. Australia also has numerous policy incentives and penalties to encourage Australians to take out private health insurance and access private hospitals, and thus private specialist health care. Private health insurance covers the hospital stay component in private hospitals. For the actual health services provided by private specialists within private hospitals, Medicare will pay a subsidy for the service, with an individual's private health insurance potentially paying for either the remainder of the charge, or patients themselves also having to pay. This will depend upon the coverage of each individual policy, and the amount charged by the provider of the service, with many private health insurance policies only providing reimbursement up to a certain amount. Only 44% of private hospital admissions had no out‐of‐pocket fees in the 2020–21 financial year;14 and in the same period only 34% of specialist attendances were bulk billed (meaning there was no out‐of‐pocket fee).7 The average out‐of‐pocket fee for out‐of‐hospital specialist and obstetric services was $98 and $303 per non‐bulk billed visit, respectively.7 Out‐of‐pocket fees are therefore a major feature of private specialist care. User fees and the role of the market in setting price Private health care services (ie, all services outside of public hospital services) are provided through the market. This means that the fee charged for services covers the cost of production (staff salaries, capital costs, and operation costs such as insurance) less any government subsidies. For providers operating on a for‐profit basis, it also includes a profit component, and the objective of such providers is profit maximisation. A recent report found that profits for private specialists increased by 11% between 2019–20 and 2020–21; profits for GPs increased by a smaller amount (2%).13 It is also notable that the average salary, before tax and after deducting practice costs, is around $400000 per year for specialists, and around $200000 per year for GPs.15 The ability of private providers of health care services to set their own fees, to cover operational costs and make profits, is a key feature of the Australian health care system. This is supported by the Australian Constitution, with government excluded from regulating fees that health care providers charge for their services.16 The fee charged, and the amount of profit, is therefore determined by an individual consumer's willingness to pay for the service. In the market, the higher the willingness to pay, the higher the service fee. This is problematic in health care as willingness to pay is constrained by ability to pay, with people at socio‐economic disadvantage — who generally have poorer health17 — having a lower ability to pay the higher prices often paid by those at socio‐economic advantage.18 Although the private market is subsidised through Medicare, patients are only reimbursed a fixed amount based on the Medicare schedule fee for each service. This schedule fee generally differs from the fees actually charged.7 The Medicare safety net reimburses patients at a higher amount (initially 85% for most out‐of‐hospital services, or 100% of GP services; increasing to 100% under the safety net) once they have reached a certain threshold of out‐of‐pocket expenditure in a year ($531.70 in March 2023). However, the disconnect between the schedule fee and the fees charged by providers still leaves patients vulnerable to open‐ended out‐of‐pocket fees (Box). The extended Medicare safety net applies when a higher threshold (in March 2023, $770 for people who have a concession card or family tax benefit, and $2414 for others) reimburses patients at 80% of out‐of‐pocket expenditure based on the actual provider fee; however, again this still leaves patients to pay a potentially high out‐of‐pocket amount. Implications for access to care With the market as the mechanism for the distribution of private care, only those with the ability to pay the market price will be able to access this care. To some extent, as a result of the dual private and public system in Australia, those who are unable to afford to pay or who are unwilling to pay the market price for private care may still be able to receive care through the public hospital system — with public hospitals providing care for all essential acute medical services, based upon urgency. However, this does not cover primary care, and waiting times in public hospitals for non‐urgent reasons might mean that people priced out of the private market are not able to achieve access. Using Queensland public hospital outpatient specialist clinics as an example, 20% of non‐urgent cardiac patients and 30% of non‐urgent respiratory patients wait more the 365 days to receive care.19 Market undermining equity Although people with higher incomes may have the ability to pay to access private specialist care, such user fees cannot themselves directly contribute to the promotion of equity. There is no direct transfer of out‐of‐pocket fees from people of higher socio‐economic status to those of lower socio‐economic status. Out‐of‐pocket fees, and by extension government subsidies, do nothing to directly subsidise access for people of lower socio‐economic status who are unable to pay market prices. This, combined with public subsidisation of private health insurance premiums ($6.2 billion per year)1 means that there is potentially a large transfer of public expenditure (Medicare subsidies for private specialist care, plus private health insurance subsidies) to wealthier people and away from lower socio‐economic status groups,20 who are more likely to be in need of care.17 Allowing the more affluent to exercise their higher ability to pay only contributes to higher inequality by allowing higher socio‐economic status groups to access care more frequently.21,22,23 Systems‐level options for change A potential option to reduce out‐of‐pocket fees and reduce affordability barriers is for the federal government to expand Medicare coverage to areas such as dental, and increase the subsidies paid through Medicare, by increasing Medicare Benefit Schedule fees. However, previous increases in Medicare rebates have not resulted in substantial out‐of‐pocket cost reductions.24 Increasing the volume of outpatient specialist care through public hospitals might be an additional option to improving equity. Although there is a skew towards higher socio‐economic status in access to Medicare services,21,22,23,25 public hospitals achieve greater equity in the provision of care than private hospitals.25,26 However, public hospitals play a vital role contributing to equity in health access once conditions arise; they do not cover primary and preventive care. The Pharmaceutical Benefits Scheme has also achieved equity in health care access.27 The Pharmaceutical Benefits Scheme differs from Medicare in that the federal government pays a set, agreed price to providers (pharmaceutical companies), and there is a maximum out‐of‐pocket price that consumers will pay for any medication. Introducing a low ceiling out‐of‐pocket fee under Medicare, whereby individuals never pay more than this amount for health care services and governments pay an agreed amount to providers, could produce more equitable access. Many other options for change have also been proposed, such as incentives for bulk‐billed private specialist services, promoting greater price transparency, and funding specific conditions in bundles of funding (rather than based on frequency of services).28,29,30 There is therefore a considerable suite of options for reform. Conclusion Out‐of‐pocket fees in Australia are already leading to patients avoiding care because of the cost. The US offers a salient reminder of the impacts of unaffordable health care. There are numerous options for reducing out‐of‐pocket fees and promoting affordability. Moving forward with active, bold reform should be a priority to ensure promotion of equity and truly universal health care in Australia. Box – Vulnerability of patients to high out‐of‐pocket fees even with the Medicare safety net* * Medicare schedule fee hypothetically set at $100 and actual provider fee hypothetically set at $130. These different amounts lead to patients being vulnerable to high out‐of‐pocket fees even with the Medicare safety net: $45 initially, or $30 with the Medicare safety net.
Emily J Callander
Health's role in achieving Australia's Sustainable Development Goal commitments
Australia's implementation of the Sustainable Development Goals must advance the nation's health and wellbeing transparently and inclusively
Claire E Brolan · Nina Hall · Sandra Creamer · Ingrid Johnston · Jaya AR Dantas
