Posted by http://www.theage.com.au/daily/980625/news/news29.html on June 25, 1998 at 21:24:41:
Victoria's fine public hospitals are being bled dry
By RICHARD HARPER
PUBLIC hospitals are under intense public scrutiny. Standards of
cleanliness have been questioned and a recent report from the
state auditor-general has identified problems with casemix
funding (funding for hospitals based on the number of medical
procedures). These criticisms, although of concern, need to be
put in the context of health care in this state.
Nowadays public hospitals are much more extensively audited
than previously, and more so than their private counterparts, or
indeed many other large organisations. It is not easy to compare
medical outcomes in the two systems. Yet it is certain that, given
the right amount of support, public hospitals can achieve excellent
results at remarkably efficient costs.
In the past two years at Monash Medical Centre, for example,
812 patients have undergone coronary artery bypass surgery
with a mortality rate of only 1.3per cent, even though 40per cent
of cases were urgent and 36per cent were over the age of 70.
Over the same period, 988 elective or semi-elective coronary
angioplasties were performed, with only one death. Similar
results have been achieved in other public hospitals. These results
are as good as anywhere in the world. What is of great concern
is that the continuing dispute between the federal and state
governments over health funding is putting these programs at risk.
It is often assumed that health care is more efficiently delivered in
the private system. At least with respect to costs, this assumption
is without basis. The private hospitals offer the convenience of
little or no waiting periods and the doctor of choice, but at greatly
increased expense. For example, the average cost in the public
sector of performing coronary angioplasty is $5500 and of a
coronary bypass operation $15,200. Even on the most
conservative estimates, these costs are between half and
two-thirds of those in the private sector, with no appreciable
difference in outcome.
In Victoria, public hospitals are predominantly funded by casemix
funding. In general, public hospitals would be financially viable if
they were given the full casemix payment for all the cases they
treated. Unfortunately this is not the case. The State Government
``caps'' total payments to an individual hospital at a level
considerably lower than the demand. Hospitals are not given
extra funding for work done above this level, even though
stringent financial penalties are applied if waiting-list targets are
exceeded or patients wait too long in emergency departments
because of a lack of beds. Hospitals can ``bid'' to do extra work,
but at discounted casemix payments well below the cost of the
service. Only a government bureaucracy could devise such a
convoluted system of funding, which is a nightmare to administer.
Furthermore, even though all public hospitals have eaten into their
capital reserves and some have gone into debt in an effort to
meet clinical demands, the State Government continues to
impose an annual 1.5per cent ``efficiency'' cut.
When is enough enough? The Government seems more
concerned with squeezing every last dollar out of the system than
with ensuring quality of health care.
Such a short-sighted approach creates uncertainty that ultimately
affects morale and performance. Even the most dedicated health
professional, faced with continuing requests to do more with less,
eventually loses heart and looks for employment in the private
sector or outside the industry. Expertise that may have taken
years to build up, if lost, is not easily replaced.
The role of the Federal Government, which provides the funding
to the states, is also crucial. Recently the Commonwealth, at
considerable expense, introduced measures to encourage people
to maintain or take out private health insurance. Despite this, the
level of private health cover has continued to decline.
The money could be more productively spent on supporting
public hospitals. While initiatives to maintain private health
insurance are to be encouraged, an equal commitment to the
public hospital system is required. If they are allowed to
deteriorate or collapse through lack of funding, more people will
be forced into the private sector and government spending will
indeed be less. Yet because health care in the private sector is
much more expensive than in the public sector, the economies
will be false, as the American experience so amply demonstrates.
Instead of spending 8.6per cent of gross domestic product on
health, we will be at the American level of 14.5per cent.
An efficient and vibrant public hospital system is the backbone of
a successful health system. Surely it is not too much to ask our
politicians to come up with an equitable system of public hospital
funding. They should be regarded as a national asset and cared
for accordingly.
Dr Richard Harper is director of cardiology at Monash Medical
Centre and head of the heart and chest program, Southern
Health Care Network. The views expressed here are his and not
necessarily those of the network.
E-mail:richard.harper@med.monash.edu.au