Healthcare expenditure on Indigenous and non-Indigenous Australians at high risk of cardiovascular disease

Cardiovascular diseases are estimated to affect 5.2% of Australians [18], 12% of Indigenous Australians [19] and have been estimated to be responsible for approximately a quarter of the gap in health outcomes between Indigenous and non-Indigenous Australians [4, 20]. CVD hospitalisations and death rates in remote and very remote areas of Australia are estimated to be 30% higher than in major cities [21]. Ensuring that Indigenous and remote communities experiencing or at risk of CVD can access appropriate care is vital to closing this gap. This study provides a unique insight into the service use patterns of this high-risk cohort. Average MBS expenditure was lower per capita for Indigenous Australians relative to other participants, in line with national estimates [8]. Most of this difference, however, resulted from remote Indigenous participants receiving significantly lower levels of Medicare-funded care. While this finding is consistent with previous literature highlighting service-gaps and difficulties in providing healthcare services to remote communities, Medicare services are also an incomplete picture of healthcare being received as many services may be funded by other sources including government grants, which previous estimates have suggested could represent up to $1,300 per person per year of services in these areas [22]. This would account for a large part of the difference in Medicare expenditure between remote Indigenous and other participants found in this study. It is worth noting though the potential equity implications resulting from a two-tiered funding system. Most notably, the additional burden on AMS providers who need to apply for and meet other requirements of these grants has been well documented [23, 24].

On the other hand, once demographic and risk-related factors were controlled for there was no significant difference in the MBS expenditure of Indigenous and non-Indigenous participants. For Indigenous individuals living in non-remote locations, other factors were more important in determining their care than their Indigeneity. This suggests that this cohort of high-risk individuals were receiving care equivalent to their non-Indigenous counterparts with similar risk levels. While it could be argued that these individuals should be receiving a greater level of care to ‘close the gap’, this is a promising result particularly given that almost all Indigenous individuals in this cohort received care at an Aboriginal-specific primary healthcare centre. The importance of Aboriginal-specific services and culturally appropriate care has been highlighted repeatedly in the qualitative literature as an essential component in ensuring that appropriate care is received by these communities [25‐28]. The findings of this study suggest that in urban areas at least, culturally-specific services can help to overcome the underutilisation of primary care services by Australia’s Indigenous communities. Further it suggests that urban Indigenous specific providers may be overcoming a historical underutilisation of Medicare as a funding source.

We were unable to separate the MBS expenditure into that relating to cardiovascular as opposed to other specialties as the majority of costs were for services such as pathology tests and general consultations which may result from a number of conditions. While a patient history of gout, diabetes and COPD were all associated with significantly higher Medicare expenditure as would be expected, morbidly obese patients were found to be receiving significantly lower levels of care receiving almost $900 less care per year than other participants and an average of under 29 services per year as opposed to 34 for other participants. This goes against findings in the literature that have found increased levels of obesity to be associated with higher expenditure [3] as well as national data indicating that obese people were more likely to see a GP than non-obese individuals [29]. While the reasons underlying this finding are not immediately apparent there are several potential explanations. First, we did not have data on the hospital service use of patients so that the difference in Medicare expenditure may be compensated by hospital expenditure if these morbidly obese individuals used more hospital services. Second, previous studies have not controlled for the presence of multi-morbidities as we have suggesting that perhaps the higher expenditure found in those studies may reflect the presence of other chronic diseases. Third, it may be the case that the morbidly obese patients are either less proactive in seeking out health services or the primary healthcare services may not be meeting the needs of this cohort. Given the increasing prevalence of obesity in Australia, it is vital to ensure that primary care providers effectively meet the healthcare needs of this population to maximise patient outcomes and minimise downstream cost impacts. In any case, this relationship between service use and obesity warrants further investigation.

There were several limitations to this analysis. First, the sample is not representative of the general Australian Indigenous population. Participants were recruited from primary care services such that they were already receiving care and many of the impediments to care discussed in the literature had already been overcome. This might lead to our estimates of expenditure being an overestimate for these communities. Further our focus on Indigenous communities likely means our cohort is not generalizable to the broader Australian population at high-risk of CVD. Second, there were too few non-Indigenous Australians living in remote locations to separate the impact of living in a remote area and that of being Indigenous. While one of the strengths of the paper was our ability to exploit patient-level data to control for risk and other socio-demographic variables there are limitations to the dataset. We did not have access to hospital data and the lack of clarity around potential alternative services being provided particularly in remote areas means that we cannot ascertain the exact level of services being accessed by these communities. Similarly, other characteristics that we could not control for may influence the healthcare spend of these individuals. Finally, our data may be affected by the higher rate of Indigenous participants who did not consent to link their trial and Medicare data.