The introduction of Medical Benefits Scheme (MBS) item numbers to reimburse health assessments (HAs) represented a major shift in support for access to health promotion and preventive care in primary care settings. The HA items provide reimbursement for doctors to evaluate patient's physical, psychological and social function in order to optimise health care and education. HA items were first introduced for older patients in 1999. [1
] The items included HAs conducted at consulting rooms and not at consulting rooms, hospitals or residential aged care facilities (referred to hereafter as non-consulting room items). [1
] Aboriginal and Torres Strait Islander people aged at least 55 years and all Australians aged over 75 years are eligible for these items. The item numbers for Aboriginal and Torres Strait Islander people and all Australians are shown in table .
MBS Health Assessment item numbers
The uptake of the HA items and other items introduced as part of the Enhanced Primary Care (EPC) program from 1999–2001 has been rigorously evaluated. HA items had the highest uptake of the Enhanced Primary Care items with around 18% of the eligible population using them. [2
] No information was available on baseline levels for the provision of HAs but the evaluation did suggest that there was an increase in the use of HAs in case study practices and that reimbursement was an incentive to completing HAs in about one third of practices. Health benefits associated with HA among older patients were relatively small [4
] and the evaluation suggested that further uptake was required to have significant impact on the health of the target populations. [3
] This was particularly true of the items for Aboriginal and Torres Strait Islander people which were used at a significantly lower rate than the items for the general population. [6
] It was suggested that this effect may have occurred either because Aboriginal and Torres Strait Islander people might be more likely to have pre-existing care plans or because Aboriginal and Torres Strait Islander people were more likely to use services (e.g. hospitals) where Medicare was not used. [7
] In either case it would be expected that the disparity should decrease over time as people required new health assessments and Medicare use among indigenous people increased. [8
In May 2004, a new item (item 710) was introduced for HAs among adult Aboriginal and Torres Strait Islander people aged 15–54 years. [8
] Adult HAs could have significant health benefits for indigenous people because of the early age of onset of chronic disease and higher rates of infectious disease in this community compared to other Australians. [10
] For example, the rate of sexually transmitted infection was halved at two year follow-up in indigenous rural and remote communities in Queensland where Well Persons Health Checks were conducted. [11
] If the new item results in increased HAs, it has the potential to greatly reduce the burden of disease among indigenous Australians; it has rightly been applauded as an example of innovative policy in indigenous health. [9
] However this enthusiasm has been tempered with concerns that the potential health benefits of the new item will not be realised because of low uptake. [9
In this study we aim to establish whether there are likely to be barriers to the uptake of the new HA item by comparing the uptake of the HA items for older people among Aboriginal and Torres Strait Islander people and the rest of the community. We also examine differences in uptake over time and differences between States and Territories. Finally we compare uptake of the HA items for older people to the uptake of the new items for Aboriginal and Torres Strait Islander people aged 15–44 years in the first three quarters after their introduction. It would be expected that structural barriers to the introduction of HAs should have decreased over since 1999 because of the introduction of the HA items. Accordingly it might be expected that the uptake of the new item might be more rapid than the uptake of the items for older Australians.
Data on the use of item numbers (700, 702, 704, 706) by year and by State and Territory were obtained from the Health Insurance Commission statistical reports. [12
] Data on the HA items was available from the last quarter in 1999 but this was not used in the general comparison because a full years data was not available. The extract included annual data from 2000–2004.
Data on the use of item numbers (700, 704, 710) in the first three quarters of their introduction was also obtained from the Health Insurance Commission statistical reports. [12
] These data are available by State and Territory but figures for the whole of Australia were used because of low numbers. For items 702 and 704 the first three quarters data was for the last quarter of 1999 and the first two quarters of 2000. For item 710 the data was from the last three quarters of 2004. It should be noted that the first quarter data may not include data for the whole quarter.
In addition to the other eligibility requirements, only one claim could be made per person in a 12 month period. Accordingly quarterly and annual data reports should only contain one observation per person. Data are available for smaller geographic areas than State and Territory, such as general practice divisions, however low numbers and a high level of suppressed data made small area analysis problematic.
Population estimates for the Aboriginal and Torres Strait Islander population aged at least 55 years and aged 15–44 years by State and Territory were obtained for the Australian Bureau of Statistics (ABS) projections from the 2001 census for the years 2001 to 2004. [13
] Population projections for the years 1999 and 2000 were obtained from series developed from the 1996 census. [14
] The projections provide a low and high series of population estimates. In this study the series used had little impact on the results. The low series is reported because it yields the most conservative estimates of the difference between Aboriginal and Torres Strait Islander people and the rest of the community. Population estimates for the general population aged at least 75 years were obtained using ABS time series data. [15
A logistic regression was conducted to analyse differences in the uptake of consulting room (700, 704) and non-consulting room (702, 706) HA items according to Indigenous status and year taking into account variation due to State and Territory. Consulting room and non-consulting room items were analysed separately because there is geographic variation in their use which may be potential source of confounding. The dependent variable was coded dichotomously using service use data to estimate the number of people who used the service and population data to estimate the number of people who did not. Year was coded to enable linear trends in uptake to be tested. Indigenous status was coded dichotomously based on whether the items were only available to Aboriginal and Torres Strait Islander people or available to all Australians.
The 12.2% of Aboriginal and Torres Strait Islander people aged at least 75 years would be eligible for the general population items as well as the Aboriginal and Torres Strait Islander specific items. All analyses were conducted twice to explore whether dual eligibility could have an impact on the results. The first set of analyses was based on observed service use. Service use among Aboriginal and Torres Strait Islander people would be underestimated in these analyses if people with dual eligibility were using general population items. The data were also analysed assuming that Aboriginal and Torres Strait Islander people aged at least 75 years accessed HAs through general population items at the same rate as the rest of community. These instances of service use were then attributed to Aboriginal and Torres Strait Islander people rather than to other Australians. Service use among Aboriginal and Torres Strait Islander people would be overestimated in these analyses because some of the people using the Aboriginal and Torres Strait Islander items are likely to be aged at least 75 years and therefore would be counted twice. Some overestimation would also be expected to occur because the observed rate of service use among Aboriginal and Torres Strait Islander people aged over 75 years is likely to be less than that for the general population.
Differences in rates of consulting room and non-consulting room service use for Aboriginal and Torres Strait Islander people and the rest of the community were calculated for each State and Territory.
A logistic regression was conducted to compare the uptake of older all Australian (700), older Aboriginal and Torres Strait Islander (704) and adult Aboriginal and Torres Strait Islander people (710) HA items. The HA item for adult Aboriginal and Torres Strait Islander people (710) was used as the reference category for comparisons. Quarter was coded to enable linear and quadratic trends in uptake to be tested. The dependent variable was coded dichotomously using service use data to estimate the number of people who used the service and population data to estimate the number of people who did not.