Our results describe the trend in the rate of emergency and elective CARPs in WA for public and private funding sources before and after the introduction of the Federal government’s private health insurance incentive policy reforms in 2000. The rates of emergency procedures – which included mainly PCIs with stenting - increased throughout the study period for both public and private patients. Elective PCIs with stenting, however, increased only for privately funded patients following the introduction of the private health insurance incentive policy reforms. This rate increase was only evident for people aged 65+ years and people living in high SES areas.
Despite the steady increase in emergency PCIs with stenting for both public and private patients throughout the study period, our results showed that the majority of these procedures continue to be performed in the public sector based on the absolute procedural rates. Over 80% of patients requiring emergency CARPs are still treated in public hospitals as a public or private patient. As such, there appears to be a core group of patients that will continue to require emergency CARPs, predominantly PCIs with stenting for management of acute coronary syndromes, and who are not influenced by private health insurance policy reforms to purchase private health. However, there was a minor impact in the sense that the proportion of emergency CARPs which were performed in private hospitals increased from 7% to 17.2% before and after year 2000. This increase in rate of emergency CARPs is likely to be attributed to many factors, including an ageing population, evidence-based practice of primary PCI for ST segment elevation myocardial infarction , and current clinical guidelines that recommend an early invasive management strategy over an initially conservative strategy for acute coronary syndrome cases [14, 15]. Our results also showed a declining trend for elective CABGs in both public and private patients. This predated the policy reforms and appears not to have been influenced by their introduction.
In our study, the rate of elective PCIs with stenting increased only for private patients from 2000 onwards. Notwithstanding controlling for increased availability of PCI since the introduction of the private health insurance incentive policy reforms, this initiative appears to have been successful in shifting elective PCIs with stenting from the public to the private sector particularly in the older age group which traditionally has been the group who are most disadvantaged in terms of access to elective surgery in public hospitals. Interestingly, the findings from this study also indicate that the increased rate of PCIs with stenting for private patients from 2000 onwards was only evident for people living in high SES areas. Therefore, it seems possible that mainly Western Australians with sufficient discretionary income were able to respond to the increased affordability of private health insurance membership following the introduction of the private health insurance policy reforms by shifting from the public to the private sector. The reason why there was not a comparable increase in rate of elective PCIs with stenting for private patients living in low SES areas is unclear because the rates of cardiovascular disease would be expected to be higher in people living in low SES areas and suggests that a person’s SES and the area in which he/she lives has a significant effect on access to health care regardless of access to private health insurance.
The shift from publicly funded to privately funded elective PCIs with stenting from 2000 would likely have relieved the economic pressure on the public sector. However, due to the high cost of these procedures in the private sector and the increasing investment of the federal government towards the private sector, the shift may in fact not have improved the economic burden on the public purse. For example, the private health insurance incentives that were introduced in 2000 involved a 1% tax-penalty for high income earners without health insurance, a 30% tax rebate on insurance premiums and a 2% premium penalty pa for those who entered after the age of 30 [1, 16]. The 50% increase in private health insurance membership following the introduction of these reforms has been attributed primarily to the introduction of the premium penalty as the 30% premium rebate was reported to increase private health insurance coverage by only 1% from 1998 to 1999 [17, 18]. It therefore seems that the most costly policy reform, i.e. the 30% rebate, did not do the trick. However, because of the 30% rebate, government funding for patients undergoing invasive cardiac procedures (F42B) was lower for public patients ($1,424 per episode) than for private patients ($2,254) in 2005–6 . In addition, since the premium rebate is 35% for people aged 65–69 years and 40% for people aged 70 years and over, the government funded a greater proportion of private patient costs for the older age groups . Furthermore, the costs of PCI procedures have been found to be more than twice as high in the private sector compared with the public sector . As a result, although it has been argued that the policy reforms were successful in relieving economic pressure on the public sector, our results present some evidence to suggest that this may not necessarily have been the case.
What appears to be more likely than a reduction in the economic pressure on public hospitals is that the policy reforms may have increased the availability of beds in public hospitals. The vast majority of public patients included in this study were treated in public hospitals and the proportion of patients undergoing CARPs in public hospitals decreased significantly from pre-2000 to post-2000. This decreasing trend was particularly evident for elective procedures. This supports our results suggesting that when private health insurance became more affordable in the year 2000, it was the elective cases that tended to transfer to the private sector. What also seems to have made this shift easier is that the number of private hospitals in Australia had been increasing since the 1990. For example, there was a 16% increase in the number of private hospitals in Australia during 1990–2000, whereas public hospital numbers increased by only 3% over the same time .
The strength of this study is reflected in the use of 14 years of routinely-collected hospital inpatient information for the entire WA population. It is a statutory requirement that the Department of Health records information on all hospital admissions and separations from all public and private hospitals in the State. The hospital data collection has undergone stringent quality assessments by the Department of Health and validation studies have confirmed the accuracy of the coding [22, 23]. Despite these strengths, some limitations require acknowledgement. Firstly, we were not able to quantify or account for the increase in catheter laboratories in metropolitan Perth or the increase in cardiologists who can perform PCIs with stenting. We can thus not say for certain whether the shift from publicly-funded elective PCIs with stenting to privately-funded elective PCIs with stenting around 2000 was due to the private health insurance incentive policy reforms alone. Secondly, we cannot distinguish between bare stents and drug eluting stents. This is a constraint since drug eluting stents were more commonly used in the private sector. They were also more expensive and delivered better near-term or early procedural outcomes compared with bare stents. And thirdly, our data showed that not all private patients were treated in private hospitals, a small proportion of the privately funded index CARP patients were treated in a public hospital.