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3.14 Access to services compared with need

Why is it important?

Data presented in this measure examine the level of access to health care for Aboriginal and Torres Strait Islander peoples compared with their need for health care. Indigenous Australians currently experience significantly poorer health status than non-Indigenous Australians. Their life expectancy at birth is 10.6 years less for males and 9.5 years less for females, and Indigenous Australians are twice as likely to rate their health as 'fair' or 'poor' compared with non-Indigenous Australians.

While the causes of illness and injury for any community operate within broad environmental, social and personal factors, the health system can: assist with prevention through population health programs (see measure 3.03); provide an immediate response to acute illness and injury (see measure 1.02); and protect good health through screening, early intervention and treatment (see measures 3.04 and 3.05) (Dwyer et al. 2004). Evidence from Australia, the United States and New Zealand indicate that health care can contribute to closing the gap in life expectancy between Indigenous and non-Indigenous populations (Griew 2008). Inequalities in health care access and use may act to further exacerbate inequalities in health status (OECD 2009). Access to health care when needed is therefore essential to closing the gap in life expectancy.

Findings

Self-reported use of services

The 2012–13 Health Survey provides the most up-to-date picture of the whole health system. In 2012–13, 44% of Indigenous Australians accessed health care in the previous two weeks (or previous 12 months for hospital). In the two weeks prior, 22% of Indigenous Australians had consulted a doctor or specialist, 19% had consulted other health professionals, 5% had visited casualty/outpatient services and 5% had seen a dentist. In the past 12 months, 18% had been admitted to hospital.

Around 83% of Indigenous Australians had consulted a GP in the previous 12 months, ranging from 88% in the ACT to 77% in the NT.

Indigenous Australians with a disability, multiple long-term health conditions and/or high/very high psychological distress were more likely to have visited a doctor/hospital than those without these conditions.

Services claimed through Medicare

In 2013–14, Indigenous Australians had 7.6 million Medicare claims, of which 3.6 million were for GP services (note: not all care delivered through Indigenous primary health care services can be claimed through Medicare). Between 2003–04 and 2013–14, there has been a significant increase in GP Medicare items claimed by Indigenous Australians; the rate has doubled and is now higher than the non-Indigenous rate. There have also been significant increases in health assessments claimed since 2009–10 and a doubling in GP management plan (GPMP) and team care arrangement (TCA) services. In 2013–14, rates for these chronic disease management items were higher for Indigenous Australians (1.6 to 1.7 times) than for non-Indigenous Australians.

The two most common Medicare items claimed by Indigenous Australians were standard GP consultations (2.3 million) and pathology (2.6 million). In 2013–14, out-of-pocket costs for services claimed through Medicare were lower for Indigenous Australians (8% of fees claimed) than non-Indigenous Australians (22% of fees claimed). Out-of-pocket costs were minimal for health assessments, GPMPs and Aboriginal Health Worker (AHW) items, and higher for specialists (21%), diagnostics (10%), allied health (8%) and imaging (6%).

Indigenous Australians were more likely than non-Indigenous Australians to have received longer GP consultations, TCAs and GPMPs as well as nurse/AHW consultations. Service claims for specialist, psychologist and dental services were lower for Indigenous Australians.

There was a clear gradient, reducing by remoteness, in rates of Medicare service claims for GP, allied health and specialist services for both Indigenous and non-Indigenous Australians. Against this gradient, rates of claims for nurse/AHW services increased by remoteness for Indigenous Australians. This also reflects types of services available in remote areas.

Medicare claim rates for private specialist care among Indigenous Australians were highest in major cities (544 per 1,000) and lowest in very remote areas (107 per 1,000).

For GP services, Indigenous Australians claimed at a higher rate across all remoteness areas compared with non-Indigenous Australians (with the greatest difference in inner regional areas and the smallest in very remote areas). The rate of GP services claimed through Medicare was lowest in the NT (3,772 per 1,000) and highest in Victoria and NSW (7,064 and 7,065 per 1,000 respectively).

Indigenous women had higher rates of total services claimed per 1,000 through Medicare than Indigenous men (1.7 times). Indigenous Australians had higher rates of services claimed in the 15–29 and 40–64 year age groups compared with non-Indigenous Australians and lower rates in the 0–14 and 65 years and over age groups.

Indigenous primary health care services

There has been a steady rise in the number of Australian Government-funded Indigenous primary health care organisations, from 108 in 1999–2000 to 205 organisations in 2012–13. Between 1999–2000 and 2012–13, episodes of health care provided to clients of these organisations have more than doubled from 1.2 million to 3.1 million. Equivalent full-time staff (both paid by the service and visiting) tripled over the same period.

Hospital care

During the two years to June 2013, there were an estimated 453,000 hospital separations for Indigenous Australians (excluding dialysis). After adjusting for age, Indigenous Australians were hospitalised at 1.3 times the rate of non-Indigenous Australians. Hospital separation rates for Indigenous Australians were highest in remote areas, lower in very remote areas and lowest in major cities.

Palliative care

Indigenous Australians were hospitalised for palliative care at 1.5 times the rate of non-Indigenous Australians between July 2011 and June 2013. Aboriginal and Torres Strait Islander peoples accounted for 1.6% of all hospitalisations for palliative care.

In 2012–13 Online Services Report data, 42% of the 205 Australian Government-funded Indigenous primary health care organisations provided palliative care (AIHW 2014a).

Elective surgery

In 2012–13, the overall rate of elective surgery for Indigenous Australians (59 per 1,000 persons) was markedly lower than for other Australians (88 per 1,000 persons) (AIHW 2014f). In 2013–14, there were 21,377 hospitalisations from public hospital waiting lists for elective surgery for patients identified as Aboriginal and/or Torres Strait Islander. Overall, the median waiting time for Indigenous Australians was greater than the median waiting time for other Australians (41 days and 36 days respectively) (AIHW 2014g).

Emergency care

In 2013–14, 73% of Indigenous Australians who presented to an emergency department were treated within national benchmarks for emergency department waiting times compared with 74% of other Australians. In terms of performance across triage categories, 100% of Indigenous Australians were treated within national benchmarks for triage category 1 (need for resuscitation), compared with 68% and 71% for triage categories 3 and 4 (urgent and semi-urgent), respectively (AIHW 2014h).

Self-reported barriers

In 2012–13, 30% of Aboriginal and Torres Strait Islander peoples reported that they needed to, but did not see a health care provider in the previous 12 months. This varied by type of service with 21% not going to a dentist, 14% to a doctor, 9% to a counsellor, 9% to other health professionals and 6% to hospital when needed. Indigenous Australians living in non-remote areas (32%) were more likely to report not seeking care when needed than those living in remote areas (22%).

Reasons for not seeking health-care in the last 12 months varied according to the type of care needed. For some services cost was the main reason for not seeking care, for others waiting times were more of a barrier. Reasons for not going to a doctor when needed included:

  • being too busy (30%)
  • waiting time too long/service not available at time required (22%)
  • transport/distance (14%)
  • dislikes service/professional or is embarrassed/afraid (14%)
  • cost of service (13%)
  • felt service would be inadequate (9%).

Cost was a major barrier to accessing dentists (43% overall and 32% in relation to children).

Service/provider availability

In 2013, there was a decline in full-time equivalent (FTE) medical practitioners as remoteness increased, from 426 per 100,000 population in major cities to 257 in remote/very remote areas (AIHW 2014s). For nurses, FTE per 100,000 population ranged from 1,265 in very remote areas to 1,111 in outer regional areas (AIHW 2014x). A geographic index of access and need developed by the AIHW showed that for Indigenous Australians access to GPs relative to need worsened with increasing remoteness (AIHW 2014b).

Private health insurance

In non-remote areas, 20% of Indigenous Australians were covered by private health insurance (up from 15% in 2004–05). The most common reason reported by Indigenous Australians for not having private health insurance was that they could not afford it (72%); up from 65% in 2004–05. Among all Australian adults, a higher proportion of adults with insurance made a dental visit in the previous 12 months (71%) than adults without insurance (48%) (Brennan et al. 2012). In the two years to June 2013, 7% of hospitalisations with a procedure recorded for Indigenous Australians occurred in private hospitals compared with 53% for non-Indigenous Australians.

Patient experience

In the 2012–13 Health Survey, 16% of Indigenous Australians reported they had been treated badly in the previous 12 months because they are Aboriginal or Torres Strait Islander. Of those, 20% felt they had been treated unfairly by doctors, nurses or other staff in hospitals or doctors' surgeries. Around 7% of Indigenous Australians reported that they avoided seeking health care because they had been treated unfairly. Most Indigenous Australians aged 15 years and over living in non-remote areas that saw a GP or specialist in the previous 12 months, reported the doctor always or usually: listened carefully to them (89%), showed respect to them (89%), and spent enough time with them (85%).

Implications

Access rates vary by type of care. GP care now shows similar rates between Indigenous and non-Indigenous Australians while rates are higher for hospital care. Indigenous Australians currently experience significantly poorer health and therefore we should expect to see access to health services 2–3 times the non-Indigenous rate.

Variations in access are associated with factors such as cost, cultural competency, and geographic barriers. Indigenous Australians have much lower levels of private health insurance, are more likely to use public hospital services and have lower rates of elective and preventive surgery. Barriers to accessing care when needed vary between remote and non-remote areas, suggesting that strategies need to be adapted for local circumstances. Recruitment and retention of staff including in rural and remote areas is also an issue (see measure 3.22).

Analysis of the data presented finds an increase in health assessments, GP management plans, team care arrangements and allied health items claimed through Medicare since the introduction of the former National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes. This partnership agreement included a range of initiatives designed to support best practice management of chronic disease.

This report also finds a continuation of the increase in funding for Indigenous-specific health services and the number of episodes of care delivered through these services.

In May 2010, the Medicare Practice Incentives Programme—Indigenous Health Incentive was introduced and aims to support general practices and Indigenous health services to provide better health care for Aboriginal and Torres Strait Islander patients, including best practice management of chronic disease.

As part of the 2014–15 Budget, the Australian Government announced that it would adopt the recommendations of the Review of Medicare Locals (MLs). Accordingly, Australian Government funding to MLs will cease on 30 June 2015, with Primary Health Networks (PHNs) commencing operations from 1 July 2015. PHNs will be outcomes-focused to improve the efficiency and effectiveness of medical services delivered to individual patients and funded by the Australian Government.

The personally controlled electronic health (eHealth) record was introduced in July 2012. Indigenous Australians have been identified as a key group for specific communication and training. The electronic health record in the NT is providing access to health summary information, pathology results and increasing coordination of health care across large distances.

The Rural Health Outreach Fund (RHOF) consolidates rural health outreach programmes (including the Medical Specialist Outreach Assistance Program) to provide a large flexible funding pool for initiatives aimed at improving access to medical specialists, GPs, allied health and other health providers in regional, rural and remote locations. Up to $101.8 million will be provided under the RHOF from 2013–14 to 2015–16.
In 2013–14, 190,460 Australians accessed services through this programme.

The Australian Government will provide up to $92.5 million under the Medical Outreach Indigenous Chronic Disease Programme from 2013–14 to 2015–16 to deliver a wide range of medical specialist, general practice and allied health outreach services to Indigenous Australians, with a focus on regional, rural and remote Australians who have a chronic disease. Services are focused on patients with diabetes, cancer, renal, cardiovascular and respiratory diseases. In 2013–14, more than 123,136 Australians accessed services through this Programme (Department of Health unpublished).

Figure 3.14-1 Comparing avoidable mortality rate ratios (2008–12) with accessing MBS GP services rate ratio (2013–14) by age group
chart showing Comparing avoidable mortality rate

Figure 3.14-1 shows a comparison of avoidable mortality rate ratios (2008-12) with MBS GP services rate ratios (2012–13) amongst Indigenous Australians. Mortality data are presented separately for the following age groups: 0-4 years, and 10 year groupings from 5-14 to 55-64 years and then 65 years and over. MBS GP services data are presented separately by 5 year age groupings from 0-4 years to 60-64 years and then 65 years and over. The avoidable mortality rate ratio peaks in the 35-44 year age group. The figure shows that while Indigenous Australians are up to around 4 times as likely to die from causes considered potentially avoidable given effective and timely health care, they are only accessing GP services at slightly higher rates than non-Indigenous Australians.

Note: avoidable mortality rate ratio includes people aged 0–74 years, NSW, Qld, WA, SA and NT.

Source: AIHW analysis of National Mortality Database and Medical Benefits Division, Department of Health Medicare Date

Figure 3.14-2 Age-standardised rates of GP services claimed through Medicare, by Indigenous status, 2003–04 to 2013–14
chart showing Age-standardised rates of GP MBS services

Figure 3.14-2 shows age-standardised GP MBS services claimed through Medicare (per 1,000 population) among Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians. Data are presented annually from 2003-04 to 2013-14. The figure shows there has been a significant increase in access to GPs by Indigenous Australians between 2003–04 and 2013–14. The Indigenous rate of GP services doubled over this period and is now higher than the non Indigenous rate.

Source: Medical Benefits Division, Department of Health

Figure 3.14-3 Number of organisations, FTE staff and episodes of care, Indigenous primary health care organisations, 1999–2000 to 2012–13
chart showing Number of organisations, FTE staff and episodes of care

Figure 3.14-3 shows annual cumulative per cent changes to number of services, staff and episodes of care at Aboriginal and Torres Strait Islander primary health care organisations between 1999-00 and 2012–13. The figure shows that over this period there has been a steady increase in the number of services; that episodes of health care provided to clients of these services have doubled from 1.2 million to 3.1 million; and that equivalent full-time staff (both paid by the service and visiting) tripled over the same period.

Sources: SAR, DSR and AIHW OSR data collections

Figure 3.14-4 Age-standardised rate of GP MBS services claimed through Medicare, by Indigenous status and state/territory, 2013–14
chart showing Age-standardised rate of GP MBS services

Figure 3.14-4 shows the age-standardised MBS claim rate (services claimed per 1,000 population) for GP items among Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians in 2013-14. Data is presented separately for each jurisdiction and Australia overall. With the exception of the NT, rates for Aboriginal and Torres Strait Islander peoples are than for non-Indigenous Australians across jurisdictions.

Source: Medical Benefits Division, Department of Health

Figure 3.14-5 Selected MBS services claimed by Indigenous Australians per 1,000 population, by remoteness, 2013–14
chart showing Selected MBS services claimed by Indigenous Australians

Figure 3.14-5 shows MBS services claimed (per 1,000 population) by Indigenous Australians, by remoteness in 2013-14. Data are presented separately for: GP items; allied health items; specialist items; pathology items; diagnostic items; and imaging items. See the body text for more discussion on this figure.

Source: Medical Benefits Division, Department of Health

Figure 3.14-6 Age-standardised hospitalisation rates (excluding dialysis) by Indigenous status and remoteness, July 2011–June 2013
chart showing Age-standardised hospitalisation rates

Figure 3.14-6 shows age-standardised hospitalisation rates (excluding dialysis) among Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians in the period July 2011 to June 2013. Data is presented separately for major cities; inner regional areas; outer regional areas; remote areas; and very remote areas. Hospitalisation rates for Indigenous Australians were highest in remote areas, lower in very remote areas and lowest in major cities.

Source: AIHW analysis of National Hospital Morbidity Database

Table 3.14-1 Selected health services by reasons for not going to health care provider when needed, Indigenous Australians aged 2 years and over, 2012–13
Doctors
Non remote
Doctors
Remote
Doctors
Total
Other health professionals
Non remote
Other health professionals
Remote
Other health professionals
Total
Hospitals
Non remote
Hospitals
Remote
Hospitals
Total
Per cent
Total needed to go to health provider in last 12 months but didn't 15 9 14 10 4 9 6 5 6
Reasons for not going to health care provider
Cost of service 15 4† 13 39 5‡ 35 8 6† 8
Waiting time too long or not available at time required 23 19 22 16 19† 17 25 22 25
Transport/distance 14 17 14 12 19† 13 16 19 17
Service not available in area 4† 7† 5 6† 9† 6† 2‡ 8† 3†
Discrimination/not culturally appropriate/ language problems 3† 2‡ 3† 3† 2‡ 2† 4† 3‡ 4†
Dislikes services/professions, embarrassed, afraid 15 10 14 13 8† 13 16 8† 14
Felt it would be inadequate 9 6 9 5 4† 5 10 8† 9
Did not trust service/provider 6 4 6 3†= 4‡ 3 8 7† 8
Too busy (work, personal or family responsibilities) 31 25 30 32 36 33 24 18 23
Decided not to seek care 34 34 34 19 24 20 37 31 36
Table 3.14-1 Selected health services by reasons for not going to health care provider when needed, Indigenous Australians aged 2 years and over, 2012–13 (continued)
Dentists
Non remote
Dentists
Remote
Dentists
Total
Counsellor
Non remote
Counsellor
Remote
Counsellor
Total
Total health services
Non remote
Total health services
Remote
Total health services
Total
Per cent
Total needed to go to health provider in last 12 months but didn't 22 15 21 10 4 9 32 22 30
Reasons for not going to health care provider
Cost of service 47 25 43 16 15† 16 39 19 36
Waiting time too long or not available at time required 20 24 20 11 26† 12 27 27 27
Transport/distance 9 22 11 11 7† 10 15 22 16
Service not available in area 5 31 9 5 14† 6 6 25 9
Discrimination/not culturally appropriate/language problems 2† 1 2† 3 8‡ 4† 4 3† 7
Dislikes services/professions, embarrassed, afraid 19 16 19 28 18† 27 23 17 22
Felt it would be inadequate 1† 1† 1† 19 12† 18 10 6 9
Did not trust service/provider 4 4† 4 12† 14† 12 9 7 9
Too busy (work, personal or family responsibilities) 21 19 21 35 29† 34 34 28 33
Decided not to seek care 11 10 11 31 40 31 29 26 29

† Estimate has a relative standard error between 25% and 50% and should be used with caution.

‡ Estimate has a relative standard error greater than 50% and is considered too unreliable for general use.

Note: comprehensive significance testing results are published in the Detailed Analyses

Source: ABS & AIHW analysis of 2012–13 AATSIHS