Can Medicare sustain the health of our ageing population?

With six reviews of the health system currently underway, health minister Sussan Ley is investigating ways to create a “sustainable” Medicare and a stronger health system. One of the main concerns is that our ageing population is putting too much of a strain on the health system.

Like other OECD countries, Australia’s population is ageing due to lower fertility rates and increased life expectancy. The proportion of Australians aged 65 years and over increased from 12.4% in June 2000 to 14.7% in June 2014 (an 18% proportional increase), and the Australian Bureau of Statistics expects it to reach 18.6% by 2030.

We decided to investigate these concerns using data from the Bettering the Evaluation and Care of Health (BEACH) program – Australia’s longest running study of general practice activity. The results are published today in our annual report.

We found that older Australians use far more primary care health resources and the proportion they are using is increasing over time. However, having these patients managed in general practice lowers overall health care costs by reducing expensive specialist and hospital visits.

Proportion of health resources older patients use

First, we compared the proportion of GP health resources older people used in 2014–15 with the proportion they accounted for in the population.

In 2014–15, people aged 65+ years accounted for 14.7% of the population, but for:

• 27.8% of all GP encounters (1.9 x more than their proportion of the population)
• 28.7% of all GP clinical face-to-face time (x2.0)
• 35.0% of all problems managed (x2.4)
• 35.8% of all medications used (x2.4)
• 30.8% of all imaging and pathology tests ordered (x2.1)
• 32.2% of all referrals made (2.2 x more than their proportion of the population).

So overall, they used about twice as many health resources as the average Australian.

Next we looked at how these proportions had changed from 2000–01 to 2014–15. We found the proportion accounted by people aged 65+ increased from:

• 22.8% to 27.8% (a 22% relative increase) of all GP-patient encounters
• 23.9% to 28.7% (a 20% relative increase) of all face-to-face GP clinical time
• 26.9% to 35.0% (a 30% relative increase) of all problems managed in general practice
• 28.2% to 35.8% (a 27% relative increase) of all medications used
• 24.9% to 30.8% (a 24% relative increase) of all imaging and pathology tests ordered
• 24.2% to 32.2% (a 33% relative increase) of all referrals made.

All these relative increases were larger than the 18% relative increase in the proportion of the population aged 65+.

We also found that older people had more diagnosed chronic conditions than younger people. Having multiple diagnosed chronic conditions increases both the complexity of the patient’s care and the resulting health resource use.

We found that 60% of people aged 65+ in the population had three or more diagnosed chronic conditions and one-in-four had five or more.

One-third of older patients at GP encounters were living with chronic pain. This was nearly always treated with medication.

Older patients were taking more medications (just over five on average) which is known to increase the risk of adverse drug reactions.

So Australia allocates significant resources to the care of over-65s. But how do we measure up internationally?

Note: PPP – Purchasing Power Parity; GDP – Gross Domestic Product; USD – United States Dollars.WHO Global Health Expenditure Database; WHO Global Health Observatory Data Repository; Life expectancy data by country

Australia’s total health care spending is similar to comparable countries (the United Kingdom, Canada and New Zealand) and we enjoy one of the world’s longest life expectancies.

However, Australia spends about half the amount the United States spends on health per head of population. Yet our life expectancy is four years longer than theirs (83 years versus 79 years).

Paying for better health

One of the biggest differences between the health care systems in Australia and the United States is that primary care is the core of Australia’s system, with GPs acting as “gatekeepers” to more expensive care.

We found nearly all older patients (98.6%) have a regular general practice they usually attend. This provides GPs in that clinic with a shared patient health record which helps continuity of care. It also lowers the risk of test duplication and fragmentation of services.

If general practice wasn’t at the core of our health care system, it’s likely the overall cost of health care would be far higher.

It is generally accepted that early diagnosis and management of chronic conditions is part of quality health care. The combination of early diagnosis and our ever-increasing life expectancy means we have more chronic conditions being managed for longer, consuming a growing amount of health resources for their management.

This is the price Australia pays for good health, but we would argue this price is very reasonable.

Care of those with complex chronic problems requires integration of services and coordination of care given by multiple providers. This includes GPs, hospitals, medical specialists, allied health professionals, and community and aged care services. This need will only increase as the population continues to age.

General practices are in a prime position to act as the coordinators of care and help lower the chance of fragmented care. If our government wants to make our health care system sustainable, it should invest in primary care to improve the integration of, and communication between, these different parts of the health system.

Further reading: view our four-page infographic here.

Helena Britt receives or has received fudnign from AstraZeneca Pty Ltd (Australia) (1998–) Australian Government Department of Health (1998–2004, 2007–) Novartis Pharmaceuticals Australia Pty Ltd (2009–) bioCSL (Australia) Pty Ltd (2010–) Sanofi-Aventis Australia Pty Ltd (2006–2012, 2015–) Australian Government Department of Veterans' Affairs (2004–) In past years other major contributors to the BEACH project have been: AbbVie Pty Ltd (2014–2015) Merck, Sharpe and Dohme (Australia) Pty Ltd (2002–2013) Pfizer Australia (2004–2013) National Prescribing Service (2005–2009, 2012–2013) GlaxoSmithKline Australia Pty Ltd (2010–2012) Bayer Australia Ltd (2010–2011) Janssen-Cilag Pty Ltd (2000–2010) Abbott Australasia Pty Ltd (2006–2010) Wyeth Australia Pty Ltd (2008–2010, then merged with Pfizer) Roche Products Pty Ltd (1998–2006) Aventis Pharma Pty Ltd (1998–2002) Australian Government Department of Veterans' Affairs (1998–2000) The Office of the Australian Safety and Compensation Council, Department of Employment and Workplace Relations (1998–2000)

Christopher Harrison is member of the NSW Greens.

Graeme Miller receives funding from: AstraZeneca Pty Ltd (Australia) (1998–) Australian Government Department of Health (1998–2004, 2007–) Novartis Pharmaceuticals Australia Pty Ltd (2009–) bioCSL (Australia) Pty Ltd (2010–) Sanofi-Aventis Australia Pty Ltd (2006–2012, 2015–). Australian Government Department of Veterans' Affairs (2004–) AbbVie Pty Ltd (2014–2015) Merck, Sharpe and Dohme (Australia) Pty Ltd (2002–2013) Pfizer Australia (2004–2013) National Prescribing Service (2005–2009, 2012–2013) GlaxoSmithKline Australia Pty Ltd (2010–2012) Bayer Australia Ltd (2010–2011) Janssen-Cilag Pty Ltd (2000–2010) Abbott Australasia Pty Ltd (2006–2010) Wyeth Australia Pty Ltd (2008–2010, then merged with Pfizer) Roche Products Pty Ltd (1998–2006) Aventis Pharma Pty Ltd (1998–2002) Australian Government Department of Veterans' Affairs (1998–2000) The Office of the Australian Safety and Compensation Council, Department of Employment and Workplace Relations (1998–2000) He is affiliated with the RACGP. and the AHHA

Allan John Pollack, Carmen Wong, Clare Bayram, Janice Charles, Joan Henderson, Julie Gordon, and Lisa Valenti do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond the academic appointment above.