Understanding the role of chronic disease and private health insurance in determining healthcare-seeking behaviour in Australia: an applied microeconomic evaluation

Understanding the role of chronic disease and private health insurance in determining healthcare-seeking behaviour in Australia: an applied microeconomic evaluation

Sound health is desirable for all and health is an essential element of human development and quality of life. There are numerous determinants (both external and internal) that influence a person’s health and healthcare utilisation or healthcare-seeking behaviour. Many of these determinants, such as income, education, age, gender, chronic diseases and location, are comparable across the global population. However, how the determinants interact and induce utilisation of healthcare services is distinctive to a specific community and the environment (health system and policies) they reside in. The healthcare system of many countries aims to ensure universal and equal access to healthcare for all. Accordingly, developed countries such as Australia provide publicly funded healthcare services for all residents. Nevertheless, past studies have documented unequal access to and use of healthcare (patients delaying or relinquishing necessary healthcare) resulting in avoidable morbidity and mortality.

Disparities in healthcare utilisation are the consequence of a complex range of individual, demographic and socioeconomic elements. There is a paucity of evidence on whether, for example, being male or female, being diagnosed with cancer or having private health insurance coverage significantly influences the pattern of healthcare utilisation among Australian patients. Hence, the objective of this research was to investigate the care-seeking behaviour or healthcare usage of patients with cancer, and of patients with private health insurance in Australia. The theoretical framework of the thesis is linked with the ‘theory of care-seeking behaviour’ developed by Lauver (1992), who argued that the probability of getting involved in health behaviour is determined by psychological variables (e.g. expectations, habits and norms), clinical variables (e.g. chronic diseases) and the surrounding environment (e.g. health system, health insurance). The results of this study confirm the validity of the theory for Australia.

This thesis is a PhD by publication and includes one systematic literature review and three cross-sectional studies using data from the Household, Income and Labour Dynamics Australia in (HILDA) survey which is collected annually and is nationally representative. This was supplemented by data from the Australian Bureau of Statistics. Several key findings emerged from the statistical analysis.

This thesis is an accumulation of four research articles. These articles are cohesive, as the key objective of all these papers were to analyse and understand healthcare utilisation or care-seeking behaviour of patients in Australia.

The purpose of Paper 1 was to assess the factors that are associated with healthcare utilisation in Australian cancer patients based on their demographic, geographic and socioeconomic backgrounds. The study concluded that demographic and sociocultural factors such as advancing age, gender, low income, low education status, rurality, lacking private health insurance, increased psychological distress and less access to specialist care were all associated with lower healthcare utilisation among cancer patients. Models of care such as general practitioner-led cancer care are preferred by younger individuals with cancer. Yet, accessing specialist care is associated with lower rates of hospitalisation. Higher levels of psychological distress increase hospital length of stay.

The objective of Paper 2 was to conduct a systematic literature review to examine gender differences in healthcare utilisation of lung cancer patients. A total of 42 studies met the eligibility criteria from 1356 potential studies. In these studies, the most commonly measured healthcare practice was surgery (number of studies =19), followed by chemotherapy (number of studies =13). All studies were from developed countries and had a higher percentage of male participants. Substantial evidence of heterogeneity in the use of treatments by gender was found. In relation to diagnosis interval and stage of cancer diagnosis, studies suggested that women had longer diagnostic intervals; nonetheless, they often get diagnosed at an earlier stage. Furthermore, women had a higher probability of using inpatient cancer-care services and surgical treatments. Conversely, men had more significant risks of readmission after surgery (number of studies =2) and longer length of stay (number of studies =2). Lastly, there were no significant gender differences in the odds of receiving chemotherapy and radiation therapy.

Paper 3 aimed to examine the healthcare-seeking (hospital, primary and preventive care) and healthcare utilisation behaviour of patients with private health insurance in Australia. The findings of the study indicated that patients with private health insurance had a higher number of hospital nights’ stay despite having a lower number of hospital admissions compared with those without private cover. Significant disparities were identified in preventive and specialist care use between patients with cover and without cover. No significant variations were observed in healthcare utilisation for patients before and after dropping their private health cover. Finally, one in four patients selected to use public hospitals over private hospitals despite holding private health insurance cover. Those insured and coming from lower socioeconomic backgrounds (e.g. lower income and education level) and those who are younger and without long-term health conditions have a higher probability of selecting public rather than private care. It is beyond the scope of this thesis to estimate the reason for this finding; however, recent studies and reports have indicated that a majority of private patients view their out-of-pocket health expenditure as too high, and the probability of paying out-of-pocket expenditure at the hospital is much higher for private patients compared to public patients.

The objective of Paper 4 was to investigate the determinants of private health insurance demand and then estimate the effect of income inequality on the private health insurance coverage rate. The previous studies included in this thesis indicated that private health insurance plays an important role in determining healthcare use (e.g. specialist care, health screening, and private hospital care) in Australia. The results of the paper showed that regions with higher income inequality have a higher percentage of the population with private health cover. The increasing wealth of the top 25% of income earners has a significant and positive relationship with private health insurance demand. Moreover, higher self-assessed health status, higher levels of education, a greater proportion of Australian citizenship and a higher proportion of the population over the age of 65, significantly increase the private health insurance coverage rate in a region. A substantial disparity was observed in private health insurance coverage within and across states in Australia.