Monday, 23 June 2014

The sick use Medicare!

One of the bright stars in the sky of Australian public service is the Parliamentary Library.  The helpful staff
.... of the Library do not spend their time pursuing Mad Monks ....
.. even if they have a preference for red garments.

Rather, amongst their other duties they put out interesting research papers addressing topics of public policy.  While these are properly aimed at the elected denizens of the House on the Hill
.. the rest of us do get to see them through Flagpost.

A recent posting to that site addressed the extent to which Concession Card holders use the bulk billing facilities of Medicare.  This is against a background of the Government introducing a co-payment of $7 for visits to a GP.  The post concludes:
"There is evidence that concessional patients are high users of health services, but that appears to reflect their poorer health status."
A first comment I will make is that nothing I stumbled across in compiling  my babble which follows leads me to disagree with that conclusion!

The Flagposts are intended to be concise so cannot cover everything of interest in a debate and I found a few points of interest that I have explored for my own benefit, and share that with you here.

[I will note that some years ago I attended a StatCan course on analysis in which it was stressed that beginning with a research objective and focusing on that is far more productive that doing an 'everything x everything' cross tabulation and hoping that something of interest drops out.  In this case I began with an idea of showing some detail about seniors and the disadvantaged and how this might relate to use of medical services.  However as I investigated various items the interesting issue arose of how the various groups overlapped each other, and that is where I have ended up.]

A key point is who are the concessional patients?  The post comments about those above 65 years of age, and also refers to "the disadvantaged" without explicitly defining the latter group.  I risked a swat from a large sword (see image above), and enquired about this.  The answer was that it is anyone with a concesssion card, thus including unemployed people and people on a disability pension as well as those who:
"... receive either the Age Pension or the Commonwealth Seniors Health Card ...."
According to the Library, citing the last FaHCSIA annual report85% of people aged 65+ get the cited benefits.  Our household don't!  Not that I am at all bitter and twisted about this.  

Again according to the Library, people in this age group (including the few like us who don't get the concession {Bitter? Twisted? Not me!}) use 30.5% of GP visits but according to the 2011 Census only include 14.0% of the resident population.  However, I am actually surprised that seniors (a much more politically correct term than 'old farts') only use twice as many GP services as the average population.

The Library post doesn't explicitly discuss the situation of those who qualify for concessional rates through receiving the Disability Pension.  However. taking the Census statistic "number of people needing assistance" as an indicator of those with a disability it seems probable that this group is to a fair extent included in the seniors.  While obviously logical this is illustrated by a graph of 2011 Census results.
A very low proportion of people who need help are employed.  Most of them are not in the labour force (which is hardly surprising given the distribution of their ages).
Looking at the percentage of people in each Labour Force Status (LFS) group who need help possibly emphasises this point.  13.9% of those not in the labour force need assistance.
The Flagpost doesn't comment directly on the uptake of bulk-billed services by 'the unemployed'.  Possibly reflecting the availability of Medicare and comparitive data, it comments instead on 'the disadvantaged' without formally defining that term.  I suspect it to be shorthand for the SEIFA Index of Relative Social Disadvantage published by ABS, to which the number of unemployed people in an area is a contributor:
 Index of Relative Socio-economic Disadvantage: is derived from Census variables related to disadvantage, such as low income, low educational attainment, unemployment, and dwellings without motor vehicles.
Not surprisingly, in view of the cost of its creation and specialised applications, SEIFA is a priced product from ABS and I am sufficiently economically rational (aka stingy) to not have access to this.  Thus I will use unemployment as an initial proxy. It is not surprising that there is relatively little duplication between the numbers of unemployed people and seniors.
A second component of 'disadvantage' is having a low income.  Obviously "low income" is a rubbery topic depending upon context.  I looked at two values of income in Census data as shown in this graph.
For the purposes of this post I will ignore the high proportion of 15-24 year olds as including a lot of folk with temporary and/or part time jobs to get them through studies.  Points of interest are that 
  • the kick-up for both <$400 and <$600 starts at the 50-55 year age group and by 65-69 years is above 70% for the higher value. 
  • the dip after 75-79 years: a very interesting topic but beyond my scope (and probably my analytical ability).
However the key point is that there is a fair level of correlation between low income and age.  Looking at it another way the next chart shows the proportion of seniors and others with various income ranges.
I have included the trend lines to emphasise how the seniors cluster/peak in the ranges $200 pw to $600 pw, while the younger folk have a very flat distribution (especially if the 'negative income' group was removed).

So again we have a fairly high level of overlapping between older folks and those with low income.  

I noted above that few of the unemployed are seniors.  However it will come as no surprise that there is a fair level of overlap between unemployment and low income!

Summarising

I have ended up in a position in which it appears that due to overlapping circumstances many people with concession cards are going to end up ticking more than one box of qualification.  This is summarised in the following schematic Venn diagram:  
I have described this as schematic since I have set the size of the circles and the overlaps between them to be roughly correct this is not guaranteed to be at all precise.

Getting back to the Flagpost which started me on looking at this, it seems quite clear that the conclusion by the author of the post is right on the money.   Further, noting the overlap with the other three characteristics I looked at, the incidence of low incomes is such that these folks will have difficulty in stumping up the $7.00 per medical service  required by Messrs Abbott, Hockey and Corman.

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