What does it cost to provide equity of access to high quality, comprehensive primary health care in rural Australia? A pilot study

Introduction: Equity of access to primary health care (PHC) services is a fundamental goal of rural health policies and planning. Unfortunately, many rural and remote communities are characterised by significant inequities in PHC service availability, quality/performance and sustainability. This article investigates how best to ascertain the costs of delivering high quality PHC services across different geographical locations through reporting the research findings from a pilot study. The aim of the study was to ascertain whether it is possible to estimate the total, per capita and per consultation costs of providing high quality PHC services in rural locations of different population sizes, and to describe the methodological issues associated with such an exercise. Methods: A retrospective, top-down approach was used. A sample of high performing primary care practices in rural communities was identified using data from the Australian Primary Care Collaborative (APCC) program. The researchers selected practices in rural communities (Australian Standard Geographical Classification remoteness areas 2 and 3) and assigned a population count using Australian Bureau of Statistics census data (urban centre locality). Four population groups of different sizes were chosen: 101-500, 501-1000, 1001-3000 and 3001-5000. A data collection tool was developed to capture information describing annual operating costs (both capital and recurring), human resources, PHC services provided and reflections from practice principals on issues related to provision of sustainable high quality primary care in a changing environment. Financial data available from practice taxation/accounting records for the 2012-13 financial year, measured in Australian dollars, was used. Practices were visited between March and July 2014. Results: Seven primary care practices agreed to participate. The data exhibited wide variation in total recurrent costs, capital and depreciation costs. There was a weak association between total annual costs and costs of practices grouped by the size of the local community. A stronger association was evident when the size of current patients registered with the practice was considered. The cost per person registered with the practice declines as the number of patients registered increases. Most of the recurrent costs for all practices were attributed to human resources and ranged from 69% to 85% with an average of 77%. Doctors' salaries accounted for 47-65% of total annual costs with an average of 53%. There was some evidence of an association between cost per consultation and the number of registered patients, with unit cost falling as the size of the registered patient population increased. Discussion: This research highlights several significant issues that need to be addressed in seeking to benchmark rural PHC services: (1) ensuring consistency across the particular services being costed in different locations, (2) consistently determining the patient population within the service catchment, (3) categorising service models, taking into account extended service provision arrangements, (4) ensuring comprehensive collection of all costs and (5) other methodological issues including disaggregating data, defining high performing services and their sustainability over time. Conclusions: Existing national health data sets should be more accessible to researchers for the purpose of benchmarking sustainable, high performing rural PHC services. National rural health and related professional peak bodies should investigate the potential to combine resources to undertake a national survey of the costs of providing high quality PHC across rural Australia.