Background: Out-of-pocket (OOP) costs may limit access to Medicare-funded allied health services; yet population-level trends in service use and costs remain unclear. Objective: To examine trends in utilisation and OOP costs for Medicare-funded allied health services used in diabetes management in New South Wales (NSW), Australia.Methods: This study used a population-level linked data asset of all Medicare-eligible adults ≥18 years residing in NSW from 2005-2020 (n = 7.4 million). Individuals with diabetes were identified based on dispensed diabetes medicines, diabetes-related medical services, and hospital admissions. Within this cohort, Medicare Benefits Schedule (MBS) claims data were used to examine annual allied health service utilisation, mean OOP costs and bulk billing rates from 2012-2021. Costs were adjusted to 2021 prices.Results: The proportion of individuals with diabetes with ≥1 allied health claim increased from 29.2% in 2012 to 34.3% in 2021. Dietetic and diabetes education service use decreased (4.3% to 2.9% and 2.0% to 1.2%, respectively), while podiatry and physiotherapy use increased (20.4% to 24.2%, and 5.2% to 7.8%). Annual bulk billing rates remained stable at 71%, but mean OOP costs for non-bulk billed services increased from AU$12.5 to $21.4 (71.2%), with costs highest for dietetic and diabetes education services.Conclusion: Medicare‑funded allied health service use remains low, with one in three individuals with diabetes accessing services annually. An increase in OOP costs following the Medicare rebate freeze (2014-2020) may present a barrier to access. Medicare reform may be required to address affordability, particularly for dietetic and diabetes education services.

Australia's healthcare system relies heavily on patient co-payments, which account for around 16% of national health expenditure. Although this percentage is in line with the OECD average, the design of co-payments is a major source of inequity and inefficiency. Current arrangements contribute to pro-rich utilisation of specialist care, regressivity in household financing, geographic variation in access and distorted incentives that discourage efficient care. These problems will be amplified by demographic ageing and rising inequality. This opinion piece synthesises the empirical evidence on the consequences of Australia's current co-payment structure and proposes reforms to improve consistency and predictability of financial signals across programmes as well as incorporate notions of capacity to pay. These reforms aim to reduce the harm imposed by current co-payments and deliver a more equitable and efficient health system.

Research Question/Issue This study examines the impact of the Chronic Disease Dental Scheme (CDDS), introduced in 2007 to provide subsidised dental care for people with chronic conditions. Specifically, it asks whether the CDDS improved access to dental care among eligible women and what characteristics were associated with receiving higher rebates.Research Findings/Insights The analysis finds no statistically significant increase in dental visits among eligible women compared to ineligible women, despite the substantial fiscal outlay of the scheme. However, CDDS rebates were more likely to benefit women experiencing financial stress, those holding concession cards and those reporting poorer dental health. Conversely, women living in regional or remote areas received substantially lower rebate, underscoring persistent geographical inequities in access.Practitioner/Policy Implications The CDDS did not increase dental access overall but did provide financial relief to some disadvantaged groups, suggesting partial success in targeting need. Future dental policy must carefully weigh costs against outcomes and address equity challenges, particularly for rural and remote populations where service provision is limited.Methods Used The study employs a difference-in-differences approach using panel data from the Australian Longitudinal Study on Women's Health (1946-51 cohort) and linked Medicare claims, alongside a Heckman selection model. The analysis is causal in design with complementary descriptive insights.

This study examines the effects of a public subsidy withdrawal on provider behaviour, focusing on General Practitioners (GPs) in Australia. Specifically, it explores changes in GP billing practices following the removal of an item on the Medicare Benefits Schedule that subsidises joint injections (intra-articular steroids). Using a difference-in-differences approach and linked administrative data, the analysis focuses on GPs who continued prescribing intra-articular steroids after the policy change. The findings indicate that GPs maintained their service volumes but adjusted their billing strategies to mitigate potential income losses, without increasing patients' out-of-pocket costs. These results highlight the adaptive responses of healthcare providers to policy-induced financial incentives, offering valuable insights for healthcare policy design and economic sustainability.

In this paper, we examine trends in provider fees charged, government expenditure on private out-of-hospital medical services, and out of pocket costs following policy changes intended to reduce government expenditure. We examine the experience of a high-need patient group: people diagnosed with cancer. The Australian system for these services is predominantly publicly funded under fee for service; with no government control on the fees charged by providers. We calculate out of pocket costs for patients in the 12 months following a cancer diagnosis and find a large variation in these costs according to the type of treatment received as well as the place of residence and presence of additional government protection. We find that volumes of services, provider fees, and out of pocket costs rose over time. These findings are especially important for a high-need patient group as out of pocket costs are considered a barrier to access to healthcare. Governments may respond to the long-term fiscal challenges by attempting to constrain benefits it pays; our results demonstrate that careful consideration of the full impact of such policies is needed.

Objectives The Victorian Healthy Homes Program investigated the impact of thermal home upgrades on energy and health outcomes in vulnerable, older individuals over winter in Victoria, Australia.Design A staggered parallel-group randomised control trial design of 984 (764 per protocol (PP)) vulnerable households and 1313 (1015 PP) individuals. The intervention group received their upgrade prior to their winter of recruitment, and the control group received their upgrade after the winter of their recruitment.Setting Western Melbourne (metropolitan) and the Goulburn Valley (regional) in Victoria, Australia.Participants 1000 households were recruited: 800 from western Melbourne (metropolitan) and 200 from the Goulburn Valley (regional).Intervention A thermal comfort and home energy efficiency upgrade of up to $AUD3500 per household.Primary and secondary outcome measures The primary outcome was the change in indoor temperature over winter and the secondary outcomes were changes in quality of life, healthcare use and costs, self-reported health measures, energy use and costs and humidity.Results A relatively low-cost and simple home upgrade (average cost $A2809) resulted in reduced gas consumption (−25.5 MJ/day) and increased indoor winter temperatures (average daily increase of 0.33°C), and a reduction of exposure to cold conditions (<18°C) by an average of 0.71 hours (43 min) per day. The intervention group experienced improved mental health as measured by the short-form 36 mental component summary and social care related quality of life measured by the Adult Social Care Outcomes Toolkit, less breathlessness and lower overall healthcare costs (an average of $A887 per person) over the winter period.Conclusions The home upgrades significantly increased average winter indoor temperature, improved mental health and social care-related quality of life and made householders more comfortable while yielding reductions in overall healthcare use and costs.Trial registration number Australian and New Zealand Clinical Trials Registry: ACTRN12618000160235.

The Victorian Healthy Homes Program (VHHP) delivered home energy efficiency and warmth upgrades to 1000 low-income households in Victoria, Australia. As Australia’s first randomised control trial (RCT) on the relationship between the home environment and health outcomes in vulnerable older adults, this paper reports the health and wellbeing outcomes focussing three quality of life (QoL) instruments. The VHHP used a staggered, parallel-group clustered RCT. All households received a home upgrade either before (intervention group) or after (control group) winter (June-September) in 2018–2020. Three surveys: the SF-36, the EQ-5D-5L, and ASCOT measured self-reported QoL. Ordered logistic regression was conducted for categorical outcomes and Ordinary Least Squares regression for continuous outcomes. Survey outcomes were analysed before and after winter controlling for age, sex, location, and year. The intervention group experienced improved physical functioning, mental health and social care related QoL after winter relative to the control group. The main influential factor (from ASCOT) was the comfort and cleanliness of the accommodation. The intervention group also reported improvements in breathlessness and less time away from usual activities and were less likely to delay seeing a specialist. A modest investment in improving housing has important health and wellbeing benefits, especially for more vulnerable individuals. Improved mental health and social care related quality of life made individuals more comfortable in winter and these effects are likely to endure over time because the upgrade is permanent. Australian and New Zealand Clinical Trials Registry: ACTRN12618000160235. Registration date: 02 February 2018.

The Extended Medicare Safety Net (EMSN) in Australia was designed to provide financial assistance to patients with high out-of-pocket (OOP) costs for medical treatment. The EMSN works on a calendar year basis. Once a patient incurs a specified amount of OOP costs, the EMSN provides additional financial benefits for the remainder of the calendar year. Its design is similar to many types of insurance products that have large deductibles and are applied on a calendar year basis. This study examines if the annual quarter within which a patient is diagnosed with cancer has an impact on the OOP costs incurred for treatment. We use administrative linked data from the Sax Institute's 45 and Up Study. Our results indicate that the timing of cancer diagnosis has a significant impact on OOP costs. Specifically, patients diagnosed in the fourth quarter of the calendar year experience significantly higher OOP costs compared to those diagnosed in the first quarter of the year. This pattern persists after controlling for different types of cancer and different stages of cancer and robustness checks. These findings have important implications for the design of the EMSN, as well as other insurance products.

OBJECTIVE:To assess the impact of the Health Care Homes (HCH) primary health care initiative on quality of care and patient outcomes. DESIGN, SETTING:Quasi-experimental, matched cohort study; analysis of general practice data extracts and linked administrative data from ten Australian primary health networks, 1 October 2017 - 30 June 2021. PARTICIPANTS:People with chronic health conditions (practice data extracts: 9811; linked administrative data: 10 682) enrolled in the HCH 1 October 2017 - 30 June 2019; comparison groups of patients receiving usual care (1:1 propensity score-matched). INTERVENTION:Participants were involved in shared care planning, provided enhanced access to team care, and encouraged to seek chronic condition care at the HCH practice where they were enrolled. Participating practices received bundled payments based on clinical risk tier. MAIN OUTCOME MEASURES:Access to care, processes of care, diabetes-related outcomes, hospital service use, risk of death. RESULTS:During the first twelve months after enrolment, the mean numbers of general practitioner encounters (rate ratio, 1.14; 95% confidence interval [CI], 1.11-1.17) and Medicare Benefits Schedule claims for allied health services (rate ratio, 1.28; 95% CI, 1.24-1.33) were higher for the HCH than the usual care group. Annual influenza vaccinations (relative risk, 1.20; 95% CI, 1.17-1.22) and measurements of blood pressure (relative risk, 1.09; 95% CI, 1.08-1.11), blood lipids (relative risk, 1.19; 95% CI, 1.16-1.21), glycated haemoglobin (relative risk, 1.06; 95% CI, 1.03-1.08), and kidney function (relative risk, 1.13; 95% CI, 1.11-1.15) were more likely in the HCH than the usual care group during the twelve months after enrolment. Similar rate ratios and relative risks applied in the second year. The numbers of emergency department presentations (rate ratio, 1.09; 95% CI, 1.02-1.18) and emergency admissions (rate ratio, 1.13; 95% CI, 1.04-1.22) were higher for the HCH group during the first year; other differences in hospital use were not statistically significant. Differences in glycaemic and blood pressure control in people with diabetes in the second year were not statistically significant. By 30 June 2021, 689 people in the HCH group (6.5%) and 646 in the usual care group (6.1%) had died (hazard ratio, 1.07; 95% CI, 0.96-1.20). CONCLUSIONS:The HCH program was associated with greater access to care and improved processes of care for people with chronic diseases, but not changes in diabetes-related outcomes, most measures of hospital use, or risk of death.

To understand what Medicare aimed to achieve, we need to revisit the medico-politics of the time, and the fear of the spectre of socialised medicine. That determined what could be changed (universal insurance and contributions according to means) and what could not (private medical service provision and fee-for-service). We consider what Medicare has achieved in terms of community acceptance, fairer contributions, affordability at its establishment; and how those aims can be assessed today. While Medicare is undoubtedly a success, there are inflexibilities in its structure that are challenging in ensuring it is fit for the next four decades.

Introduction: The Victorian Healthy Homes Program (VHHP) is the first randomised control trial (RCT) in Australia that investigates the impact of thermal home upgrades on energy and health outcomes in vulnerable individuals over winter in Victoria Australia. Methods: A staggered parallel-group RCT design of 984 vulnerable households. The intervention group received their upgrade prior to their winter of recruitment and the control group received their upgrade after the winter of their recruitment. Results: A relatively low-cost and simple home upgrade (average cost AU$2,809) resulted in reduced gas consumption (-25.5 MJ/day) and increased indoor winter temperatures (average daily increase of 0.33C), and a reduction of exposure to cold conditions (<18C) by an average of 0.71 hours (43 minutes) per day. The intervention group experienced improved mental health as measured by the SF-36 mental component summary and social care related quality of life measured by adult social care outcomes toolkit (ASCOT), and lower healthcare costs overall (an average of AU$887 per person) over the winter period. Conclusions: The home upgrades significantly increased average winter indoor temperature, improved mental health and social care-related quality of life, and made householders more comfortable while bringing about reductions in overall healthcare use and costs. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial ACTRN12618000160235 ### Clinical Protocols ### Funding Statement The Victorian Healthy Homes Program is funded by the Victorian State Government through the Sustainability Victoria Fund. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval was received from Victorian Department of Human Services (DHS) Human Research Ethics Committee, University of Technology (UTS) Sydney Human Research Ethics Committee and Australian Government Department of Veterans' Affairs (DVA). The Victorian Healthy Homes Program is funded by the Victorian State Government through the Sustainability Victoria Fund through Sustainability Victoria I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data are held in a Secure research environment (SURE) and are archived. They are not available to other researchers because of the consent and ethics required by the various Government authorities who manage health data.

This study examines the impact of social insurance benefit restrictions on physician behaviour, using ophthalmologists as a case study. We examine whether ophthalmologists use their market power to alter their fees and rebates across services to compensate for potential policy-induced income losses. The results show that ophthalmologists substantially reduced their fees and rebates for services directly targeted by the benefit restriction compared to other medical specialists' fees and rebates. There is also some evidence that they increased their fees for services that were not targeted. High-fee charging ophthalmologists exhibited larger fee and rebate responses while the low-fee charging group raise their rebates to match the reference price provided by the policy environment.

BACKGROUND:Australia is undergoing general practice funding reform, with recent changes to Medicare and the introduction of MyMedicare voluntary patient registration. OBJECTIVE:Within this context, we provide general practitioners (GPs) with an explainer on health economic concepts relevant to current funding reform debates. This article outlines different funding model types, discusses the theoretical advantages and disadvantages of each funding model, and reflects on past experiences of reform. DISCUSSION:Common GP funding models across the world include fee for service, capitation, pay for performance and bundled payments. Each funding model has its potential advantages and disadvantages. Blended funding models can minimise undesired consequences of individual funding models but can introduce additional complexity. The challenge remains to design funding models that enable access to quality care, adequately pay providers and are sustainable into the future.

OBJECTIVES:To examine out-of-pocket costs incurred by patients for radiation oncology services and their variation by geographic location.DESIGN:Analysis of patient-level Medical Benefits Schedule (MBS) claims data linked with data from the Sax Institute 45 and Up Study.SETTING, PARTICIPANTS:People who received Medicare-subsidised radiation oncology services in New South Wales, 2006-2017.MAIN OUTCOME MEASURE:Mean out-of-pocket costs for an episode of radiation oncology (during 90 days from start of radiotherapy planning service), by geographic location (postcode-based), overall and after excluding episodes with no out-of-pocket costs (fully bulk-billed).RESULTS:During 2006-2017, 12 724 people received 15 506 episodes of radiation oncology care in 25 postcode-defined geographic areas. The proportion of episodes for which the out-of-pocket cost was less than $1 increased from 39% in 2006 to 76% in 2017; the proportion for which out-of-pocket costs exceeded $500 declined from 43% in 2006 to 10% in 2014, before increasing to 17% in 2017. For care episodes with non-zero out-of-pocket costs, the mean amount rose from around $1186 to $1611 per episode of care during 2006-2017. The proportion of radiation oncology episodes bulk-billed exceeded 90% in nine areas; in seven areas, all with exclusively private care provision of radiation oncology, it was 21% or smaller. Within geographic areas, out-of-pocket costs for individual care episodes varied widely; in ten areas with lower bulk-billing rates, the interquartile range for costs ranged from $240 to $1857.CONCLUSION:Out-of-pocket costs are an important determinant of access to care. Although radiotherapy costs for most people are moderate, some face very high costs, and these vary markedly by location. It is important to ensure that radiation oncology services remain affordable for all people who need treatment.

Using Australian general practitioners (GPs) as a case study, this paper examines the impact of a public subsidy withdrawal on provider behaviour. The removal of the joint injection item from public insurance provides an opportunity to examine behavioural changes in the context of the removal of a specific rebate while all other services are unaffected. We focus our analysis on GPs who continue to prescribe intraarticular steroids after the implementation of the policy. Using administrative data, we examine whether GPs change their billing practice and/or fees for services remaining under the universal insurance program to compensate for potential policy–induced income losses in the short–term. The estimated results for changes in billing pattern and payments provide evidence in support of physicians protecting their revenue base while not increasing the out-of-pocket cost for their patients.

Objective To elucidate the policy implications of recent trends in the funding of radiotherapy services between 2009-10 and 2021-22. Method We use national aggregate claims data to determine time trends in the fees, benefits and out-of-pocket (OOP) costs of radiotherapy and nuclear therapeutic medicine claims funded through the Medicare Benefits Schedule (MBS) program. All dollar figures are expressed in constant 2021 Australian dollars. Results Radiotherapy and nuclear therapeutic medicine MBS claims increased by 78% whereas MBS funding increased by 137% between 2009-10 and 2021-22. The main driver of Medicare funding growth has been the Extended Medicare Safety Net, which has increased by 404%. Over the 13 year observation period, the percentage of bulk-billed claims peaked in 2017-18 at 76.1% but fell to 69.8% in 2021-22. For non-bulk billed services, average OOP costs per claim increased from $20.40 in 2009-10 to $69.78 in 2021-22. Conclusion Despite increased Medicare funding, patients face increasing financial barriers to access radiation oncology services. Policies with regard to funding radiotherapy services should be reviewed to ensure that services are easily accessible and affordable for all those needing treatment and at a reasonable cost to Government.

In a bid to improve quality of care, numerous countries have incorporated rewards and penalties into the funding and pricing of hospital services. This paper outlines recent advances in Australia to incorporate financial penalties for hospital acquired complications (HACs) and avoidable hospital readmissions (AHRs) adjustments into the funding of public hospital services. It describes the work in the development of suitable measures to identify episodes, the design of the analytical approach used for risk adjustment and the calculation of the funding implications including dampening effects to account for the level of risk. Using the 2019 to 20 round of data collection, this paper reports on the risk adjustment analysis, incremental costs of HACs and AHRs, and the funding dampening effects, the paper further discusses the implementation strategies undertaken by the Independent Health and Aged Care Pricing Authority (IHACPA) to ensure transparency, stakeholder consultation and engagement. The paper argues that both the technical development and its implementation strategies have been central to making safety and quality an integral and accepted part of Australia's public hospital funding arrangements.

Background International evidence suggests patients receiving cardiac interventions experience differential outcomes by their insurance status. We investigated outcomes of in-hospital care according to insurance status among patients admitted in public hospitals with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). Methods We conducted a cohort study within the Australian universal health care system with supplemental private insurance. Using linked hospital and mortality data, we included patients aged 18 + years admitted to New South Wales public hospitals with AMI and undergoing their first PCI from 2017–2020. We measured hospital-acquired complications (HACs), length of stay (LOS) and in-hospital mortality among propensity score-matched private and publicly funded patients. Matching was based on socio-demographic, clinical, admission and hospital-related factors. Results Of 18,237 inpatients, 30.0% were privately funded. In the propensity-matched cohort ( n = 10,630), private patients had lower rates of in-hospital mortality than public patients (odds ratio: 0.59, 95% CI: 0.45–0.77; approximately 11 deaths avoided per 1,000 people undergoing PCI procedures). Mortality differences were mostly driven by STEMI patients and those from major cities. There were no significant differences in rates of HACs or average LOS in private, compared to public, patients. Conclusion Our findings suggest patients undergoing PCI in Australian public hospitals with private health insurance experience lower in-hospital mortality compared with their publicly insured counterparts, but in-hospital complications are not related to patient health insurance status. Our findings are likely due to unmeasured confounding of broader patient selection, socioeconomic differences and pathways of care (e.g. access to emergency and ambulatory care; delays in treatment) that should be investigated to improve equity in health outcomes.

The use and costs of health care rise substantially in the months prior to death, and although the use of palliative care services may be expected to lead to less costly care, the evidence is mixed. We analysed the costs of care over the last year of life and the extent to which these are associated with the use and duration of specialist palliative care (SPC) for decedents who died from cancer or another life-limiting illness. The decedents were participants in a cohort study of older residents of the state of New South Wales, Australia. Using linked survey and administrative health data from 2007 to 2016, two cohorts were identified: n = 10,535 where the cause of death was cancer; and n = 11,179 where the cause of death was another life-limiting illness. Costs of various types were analysed with separate risk-adjusted linear regression models for the last 1, 3, 6, 9 and 12 months before death and for both cohorts. SPC was categorised according to time to death from first contact with the service as 1–7 days, 7–30 days, 30–180 days and more than 180 days. SPC use was higher among the cancer cohort (30.0