Good, better, best … let’s talk about healthcare limits

In the 1980s, the top-of-the-line technology for cardiovascular problems was a pacemaker costing around $4,000. The top-of-the-line cardiovascular technology for 2007 will be a defibrillator costing around $100,000.

Five years ago, a top-of-the-line stainless steel hip joint prosthesis was around $4,000. Now a titanium model can cost $20,000.

The technological component of healthcare costs is estimated to be increasing at between 12 and 18 per cent per year, easily outstripping even the cost of drugs. And drugs themselves are expected to outstrip the cost of doctors and hospitals combined some time in the next 10 years.

So, is everyone entitled to the best possible healthcare or simply satisfactory healthcare? And who should decide what’s satisfactory, who’s entitled and who will pay for what?

One of the interesting things that Jim Bacon did, as Premier of Tasmania, was to engage the Tasmanian community in a discussion about the ends and goals of government - what did people want and expect and how would they measure success. Regardless of whether that dialogue was eventually successful or not, there is a growing need for a far-sighted political leader to begin such a community discussion with the whole population about the objectives and costs of healthcare in Australia.

No matter how much we argue for reallocation of resources from other areas of Government expenditure to health, there will always be a finite amount of resources. The issue is how should those finite resources be spent?

A specialist with access to a new technology will always use it, certainly regardless of economics and sometimes regardless of outcomes. And, given any likelihood of moderately enhancing their own or a family member’s quality, or chance, of life, patients and families will also demand the latest technology or the latest treatment, regardless of cost.

Hence the age at which premature babies are being sustained and kept alive is being gradually but steadily pushed back further into gestation, sometimes regardless of the levels of handicap that may eventuate. Similarly, the age at which doctors revive people, often to a dubious quality of life, is steadily increasing. And in-between birth and death, we are increasingly looking for a Rolls Royce model of healthcare, regardless of the bill.

None of those things are innately bad. A premature baby who survives, regardless of handicap, may feel that it is still better to be alive than not. Similarly, for the newly revived septuagenarian. And certainly I will want that defibrillator if ever I need one.

But the fact is that such decisions are no longer just individual medical decisions that ought to be left solely to patients and their doctors. In an increasingly aged society, where the rate of consumption of medical procedures will only increase, these are decisions in which the community might wish to have a say. For example, the difference between a stainless steel and a titanium prosthesis might represent ten cataract operations. A top-of-the-line defibrillator represents 20 to 30 knee or hip replacements.

The community might well see itself as justified in setting standards of care for the public health system. I suggest that it would be socially divisive and unreasonable to suppose that those with private insurance can make choices - while those dependent on the public system can’t. The reality is that the public pays for all these choices directly or indirectly, for example, for example through the taxpayer-funded rebate for increasingly expensive private health insurance.

Rather than driving state health budgets into economic ruin or adopting a covert policy that only those with private insurance are entitled to “top shelf” healthcare, perhaps it’s time to discuss openly and clearly what we are prepared to pay for as a community - for everyone, public and private. Including limits to health insurance rebates and hence what such insurance will pay for.

Perhaps this might be something Labor would like to do while it has so little of importance to do in Canberra for the next couple of years. Instead of Medicare Gold schemes, the party might engage the electorate in discussing what resources should be put into health and how those resources should be allocated. Jim Bacon showed how it might be done. Or, if Labor isn’t interested, perhaps Liberal parties could do it at the state level.

Impossible? Maybe. Worthwhile trying? Absolutely. Until we decide whether we’re all entitled to titanium joints and top-of-the-line defibrillators, we’ll continue to have arguments about the inadequacies of public hospitals and healthcare in this country.