We compare strategies to manage surgical waiting times in Australia, Canada, England, New Zealand, and Wales to give policy insights into those that are most effective. Most of these countries have allocated dedicated funding and set explicit waiting time targets. Of the five countries, England has achieved the most sustained improvement, linked to major funding boosts, ambitious waiting-time targets, and a rigorous performance management system. While supply-side strategies are used in all five countries, New Zealand and parts of Canada have also invested in demand-side strategies through the use of clinical criteria to prioritize access to surgery.

The impacts of changes to private health insurance (PHI) policies introduced since 1999 -in particular the 30% PHI rebate and the Lifetime Health Cover -have been much debated. We present historical analyses of the impacts in terms of the proportion of Australians having hospital insurance cover under different PHI policies, by age, gender and socioeconomic status, and project these to 2010 using a new Private Health Insurance coverage model.The combined effect of the 30% rebate and Lifetime Health Cover was to increase PHI membership from just over 30% in 1998 to just under 50% by the end of 2000, due mainly to more people taking out PHI cover from among the richest 20% of the population. Among the poorest 40% the impact was minimal. Model projections suggested that, had the new PHI policies not been introduced, then the proportion of Australians with PHI would have declined to around 20% by 2010, compared with 40% if the current arrangements remained in place. Also, analysis of 2001 survey data regarding choices to use a public or a private hospital indicated that higher income groups with or without PHI were the more likely to have used a private hospital than lower income groups. Among those with PHI, older people were more likely to have used a private hospital than ALTHOUGH IN RECENT DECADES the health of populations in developed countries like Australia improved considerably, the related expenditures tended to outpace economic growth. This resulted in nations searching for ways to contain costs, most typically in the hospital sector, such as the passing on of a larger share of the costs to individuals. 1,2 Examples of this latter approach are the Federal government' s recently introduced policies to increase the take-up of private health insurance (PHI). Basically, the policies are the 30% private health insurance rebate, Lifetime Health Cover and the Medicare Levy Surcharge (Appendix A). When the 30% rebate was introduced, one stated aim was to ease the burden on Medicare, in particular on public hospitals.A recent inquiry 3 examined the issue of whether these policies had achieved their aim of easing the burden on public hospitals. While researchers What is known about the topic? Recent changes in private health insurance (PHI) policies were motivated partly by concern about the continuing decline in the number of people purchasing PHI. The changes have been effective in reversing the decline in the short term and have led to strong increases in coverage among younger people. What does this paper add?Modelling of the impact of policy settings indicates that removal of the 30% rebate would cause a small drop in proportion covered compared to the impact of removal of life-time cover in combination with the rebate. Under all scenarios, the model indicates continuing long-term decline in the proportion of the population purchasing PHI. Under current policies, the proportion covered would decline to 40% by 2010. What are the implications?Removal of the 30% rebate would have a considerably lesser impa...

Study Design. Record linkage study using healthcare utilization and costs data. Objective. To identify predictors of higher acute-care treatment costs and length of stay for patients with traumatic spinal cord injury (TSCI). Summary of Background Data. There are few current or population-based estimates of acute hospitalization costs, length of stay, and other outcomes for people with TSCI, on which to base future planning for specialist SCI health care services. Methods. Record linkage study using healthcare utilization and costs data; all patients aged more than or equal to 16 years with incident TSCI in the Australian state of New South Wales (June 2013–June 2016). Generalized Linear Model regression to identify predictors of higher acute care treatment costs for patients with TSCI. Scenario analysis quantified the proportionate cost impacts of patient pathway modification. Results. Five hundred thirty-four incident cases of TSCI (74% male). Total cost of all acute index episodes approximately AUD$40.5 (95% confidence interval [CI] ±4.5) million; median cost per patient was AUD$45,473 (Interquartile Range: $15,535–$94,612). Patient pathways varied; acute care was less costly for patients admitted directly to a specialist spinal cord injury unit (SCIU) compared with indirect transfer within 24 hours. Over half (53%) of all patients experienced at least one complication during acute admission; their care was less costly if they had been admitted directly to SCIU. Scenario analysis demonstrated that a reduction of indirect transfers to SCIU by 10% yielded overall cost savings of AUD$3.1 million; an average per patient saving of AUD$5,861. Conclusion. Direct transfer to SCIU for patients with acute TSCI resulted in lower treatment costs, shorter length of stay, and less costly complications. Modeling showed that optimizing patient-care pathways can result in significant acute-care cost savings. Reducing potentially preventable complications would further reduce costs and improve longer-term patient outcomes. Level of Evidence: 3

Objective: To investigate whether the ‘inverse care law’ applies to New South Wales (NSW) hospital admissions ‐ especially to older people with high socio‐economic status (SES). Design: Cross‐sectional study analysing inequalities in public and private hospital admission rates by SES, defined in terms of age, sex and family income/size at the small geographic area level. Setting: Admissions to NSW public and private hospitals in 1999–2000 (1.8 million admissions against a NSW population of 6.4 million). Methodology: Inequalities in hospitalisation rates were expressed as rate ratios across the most and least disadvantaged 20% of the NSW population. Results: Public hospital admission rates for people aged 0–60 years were 24–35% higher for the most disadvantaged 20% of the NSW population than for the least disadvantaged 20%. For 70+ year‐olds the direction of this difference was reversed ‐ being 14% lower for the most disadvantaged 20% of the population (5% higher for public patients). For private hospitals this reversal prevailed for all age groups (23–49% lower). For all hospitals it was 16% and 27% lower for 60–69 and 70+ year‐olds respectively, with higher admission rates for top SES 60+ year‐olds most pronounced for renal dialysis, chemotherapy, colonoscopies and other diagnostic scopes, rehabilitation and follow‐up, and cataract operations. Conclusion: While the ‘inverse care law’ did apply to 60+ year‐olds, it did not apply either to younger NSW hospital users or to public patients in public hospitals. Implications: Awareness of these SES‐level differentials should result in greater equality of access to hospital services, especially by older people.

Objective: To study the effectiveness of recent private health insurance (PHI) reforms, in particular the 30% rebate and Lifetime Health Cover, in terms of their stated aim of reducing the load on public hospitals. Methods:Combines the use of two new projection models -"Private Health Insurance" (PHI) and "New South Wales Hospitals" that use public and private hospital inpatient data from 1996-97 to 1999-2000, and NSW population and private health insurance coverage statistics. Results:With the PHI reforms 15% fewer individuals would use public hospitals in 2010 than without these reforms (around 18% fewer among the 40% most affluent Australians and 9% among the 40% least affluent). Lower public hospital usage would mainly be due to Lifetime Health Cover. IN RECENT DECADES the health of the population in developed countries improved dramatically, but the related public health expenditures outpaced economic growth. This forced governments to contain costs (largely in the hospital sector), to find new funds or to pass a larger share of the costs on to individuals. Conclusion1,2 This latter approach is the aim of the Australian federal government' s policies to increase the take-up of private health insurancethat is, the 30% private health insurance (PHI) rebate, Lifetime Health Cover and the Medicare Levy Surcharge. A recent Senate inquiry noted that two of the rebate' s objectives were to make PHI more affordable and to reduce the load on public hospitals, 3 but concluded that there were insufficient analyses on whether the new PHI policies had achieved this latter aim.The paper reports on the current and projected impact of the new PHI policies on public hospital utilisation in NSW, linking two new analytical tools: the "Private Health Insurance Model" and the "NSW Hospitals Model". Because Australians with higher incomes are more likely to have hospital insurance, the impact of the new PHI policies on groups with different socioeconomic status (SES) was also studied. What does this paper add?The two modelling techniques used suggest that the reforms, in particular the Lifetime Health Cover, would lead to a 15% reduction in NSW public hospital utilisation by 2010. What are the implications for practitioners?This study suggests that Lifetime Health Cover will assist in meeting the government aim of reducing the load on public hospitals.