Elsevier

Social Science & Medicine

Volume 53, Issue 12, December 2001, Pages 1641-1651
Social Science & Medicine

Determinants of general practitioner use among women in Australia

https://doi.org/10.1016/S0277-9536(00)00449-4Get rights and content

Abstract

This study investigates the use of general practitioner services by women in Australia. Although there is a universal health insurance system (Medicare) in Australia, there are variations in access to services and out of pocket costs for services. Survey data from 2350 mid-age (45–50 years) and 2102 older (70–75 years) women participating in the Australian Longitudinal Study on Women's Health were linked with Medicare data to provide a range of individual and contextual variables hypothesised to explain general practitioner use. Structural equation modelling showed that physical health was the most powerful explanatory factor of general practitioner use. However, after adjusting for self-reported health, out of pocket cost per consultation was inversely associated with use of services. The out of pocket cost was generally lower for women with low socioeconomic status but cost was also directly related to geographical remoteness. Women living in more remote areas had higher out of pocket costs and poorer access to services. Women who reported better access to care were more likely to be satisfied with their most recent general practice consultation and less likely to be sceptical of the value of medical care. These results show the need for health policies that improve the equitable use of general practitioner services in Australia.

Introduction

General medical practice is the first point of contact for access to most health services in Australia. According to the 1995 National Health Survey, 50% of males and 60% of females had consulted a doctor within the previous three months (Australian Bureau of Statistics, 1997). General practitioners (GPs) provide a range of primary care services and referral to consultant physicians and specialists (Commonwealth Department of Health and Family Services, 1996). Patients can visit any GP at any time — they are not committed to one practice, practitioner or location. To facilitate access to primary medical care in Australia, there is a universal system of health insurance (Medicare) for all residents, regardless of age or circumstances. The Medicare system was designed to provide medical care at minimal cost to the patient with rebates paid to patients on a fee-for-service basis.

There are variations in the use of health care services in Australia according to age, sex and area of residence (Australian Institute of Health and Welfare, 1998). It is important to determine whether this variation reflects an equitable use of resources, because of uncertainties of future medical manpower requirements, at a time of potential oversupply and maldistribution of GPs, and because there is a perceived need for improved efficiency in the health care system.

Equity is most appropriately judged by use of services relative to some measure of need (Andersen & Aday, 1978). The most likely explanation for much of the variation in use of health services is variation in health status. However individual factors that may predispose, enable or impede use of services and the context of health service use, including environmental factors and provider-related variables, must be considered (Andersen, 1968; Ande`rsen & Newman, 1973; Aday & Andersen, 1974). A review of 139 studies of formal medical care utilisation in a variety of countries over the last 20 years found that the context of use, and the complex relationships that occur between individual and contextual variables, were largely neglected (Phillips, Morrison, Andersen, & Aday, 1998). This occurred despite the conceptualization and measurement of access being seen as the key to the understanding and formulating of health policy (Andersen, 1995; Gold, 1998).

Out of pocket costs may affect how often consumers use health services, both curative and preventive. The need for health care is often unpredictable and some Australians cannot budget for even modest health costs on a regular basis (Loftus-Hills, 1993). Although Medicare provides a fixed rebate for service fees (85% of the fee set by the government) there is no legislation restricting the amount a doctor can charge for a service. The patient is responsible for paying the difference between the charge for the service and the rebate, known as the “out of pocket” cost. GPs can choose to bill the government directly and accept the rebate as full payment, resulting in no out of pocket cost to the patient (known as bulk billing). There is some evidence that older people and those living in socio-economically disadvantaged areas in Australia have higher bulk-billing rates (McClelland, 1991) but there has been a lack of data to assess the effect that direct financial cost has on the use of health services. Health beliefs, such as attitudes towards health services and values concerning health, may also explain some of the variation in use of health care services. Satisfied patients are more likely to consult a GP when they have symptoms, to follow the GP's advice and to return for follow-up (Lewis, 1994).

There have been relatively few studies worldwide of the determinants of health service utilisation among women (Phillips et al., 1998). In Australia, women are more frequent users of the health care system than men (Australian Institute of Health and Welfare, 1998). To provide a basis for improved health policies and services for women, the Australian Longitudinal Study on Women's Health (ALSWH) began in June 1995. The initial objective of the longitudinal study was to establish baseline prevalence data on a broad range of health indicators and to examine associations between health indicators, health care utilisation and quality of life in women. The study provided an opportunity to seek women's views about the health care system and how it meets their needs. This paper develops the proposition that the utilisation of GP services by women in Australia is not determined solely by medical need and assesses the relative importance of various individual, environmental and provider-related determinants of use.

The factors that influence the use of health services, and the interdependencies among those factors, may well differ according to the type of service used. In this study a range of explanatory variables for GP use were considered. Predisposing factors included education, worry about health, propensity to seek care, medical scepticism and health locus of control. Variables that may affect the ability to secure services (enabling variables) included out of pocket costs, continuity of care and access to and satisfaction with GP services. Several indices of physical and mental health status were included. A conceptual model to represent the network of relationships among variables and to assess the effects of these variables on GP use is presented in Fig. 1. Some factors thought to influence GP use were considered to be influenced themselves by other factors within the model. For example, out of pocket cost per visit was hypothesised to be determined by socioeconomic and geographic factors, based on previous Australian research (McClelland, 1991; Richardson, 1993). Some attitudinal factors such as satisfaction, scepticism and worry about health were hypothesised to be influenced by other individual and contextual variables (Andersen & Newman, 1973; Wolinsky & Johnson, 1991; Strain, 1991; Fylkesnes, 1993; Lewis, 1994; Bindman et al., 1995; Bazargan, Bazargan, & Baker, 1998; Fiscella, Franks, & Clancy, 1998; van der Meer & Mackenbach, 1998). In this study, previous use of GP services was not used as a predictor of subsequent use because while previous use of services may help to predict subsequent use, it adds little information to explain why the use occurred. The variables in the model are described in detail in the Methods section.

Section snippets

Methods

The present research uses record linkage to combine two sources of survey data for the mid age and older cohorts of the Australian Longitudinal Study on Women's Health, with health service use and financial data from the Health Insurance Commission, which administers the Medicare system.

Characteristics of the sample

There were 2350 mid-age and 2102 older participants in the ALSWH baseline survey who completed the HSS questionnaire and had at least one GP visit recorded by the HIC database in the two-year period. Results are presented in detail for the mid-age group only. Eight percent of women in the mid-age group had missing data on at least one variable, with the SF-36 scores having the highest percentage (5%) missing. Table 1 shows the socio-demographic and health characteristics of women (both for

Discussion

This study was undertaken to identify determinants of GP use by women in Australia, related to their health and socio-demographic characteristics, the nature of the communities in which they live and health service provision. The results of the multivariate analyses presented in this paper are consistent with findings reported in the literature, although very few previous studies have used statistical techniques other than regression analysis and no other studies have incorporated out of pocket

Acknowledgements

The Australian Longitudinal Study on Women's Health, which was conceived and developed by groups of inter-disciplinary researchers at the Universities of Newcastle and Queensland, is funded by the Commonwealth Department of Health and Aged Care. We thank all participants for their valuable contribution to this project.

References (39)

  • Australian Bureau of Statistics (1997). 1995 National Health Survey: Summary of results, Australia. Australian Bureau...
  • Australian Institute of Health and Welfare (1998). Australia's Health 1998. Australian Institute of Health and Welfare,...
  • M Bazargan et al.

    Emergency department utilization, hospital admissions, and physician visits among elderly African American persons

    The Gerontologist

    (1998)
  • A.B Bindman et al.

    Preventable hospitalizations and access to health care

    Journal of the American Medical Association

    (1995)
  • W.J Brown et al.

    Women's Health AustraliaRecruitment for a national longitudinal cohort study

    Women & Health

    (1998)
  • W.J Brown et al.

    Women's Health AustraliaOn the progress of the main study cohorts

    Journal of Women's Health

    (1999)
  • Commonwealth Department of Health and Family Services (1996). General practice in Australia: 1996. Australian...
  • Davies, A. R., & Ware, J. E. J. (1991). GHAA's Consumer satisfaction survey and user's manual (2nd ed). The Group...
  • Department of Primary Industries and Energy and Department of Human Services and Health (1994). Rural, remote and...
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