Why the proposed Health Care Homes are not about patient-centred care

hch

Capitation and hospital avoidance: Is this really the biggest health reform in a generation?

Many of my patients ask for better quality of life, independence or patient-centred care. Patients also want their care teams to be on the same page. The government’s Health Care Home model seems to be about capitation and to some extent hospital avoidance, and may not address the needs of patients.

Although the model has some elements that may reduce potentially avoidable hospitalisations, it does so half heartedly. Participating GP practices will likely have to categorise their patients using a data extraction tool based on the UK’s QAdmissions algorithm and the Hospital Admission Risk Profile (HARP) questionnaire.

Data extraction

The government will be extracting patient data from general practice in various ways

The patient risk selection tool, which has not yet been released by the government, will be going through GP patient databases like a big vacuum cleaner to determine disease complexity and predicted demand for unplanned acute care services. Higher risk categories will attract a slightly higher practice payment.

What’s missing is just about everything else – in particular a comprehensive multi-pronged approach shared by primary care providers and hospitals, incentivising multidisciplinary patient-centred team care.

Capitation model

Although the government talks about a new bundled payment approach, practices are paid a lump sum per patient regardless of how many services the patient receives – as far as I know this is the definition of a capitation system.

How will the proposed model further improve the way care is delivered to people with chronic and complex health conditions? Will it incentivise multidisciplinary care? Does it reach across silos and improve communication? Is the proposed change of payment system in combination with a hospital avoidance risk stratification tool enough to deliver the comprehensive, coordinated care many of our patients need?

The government’s Health Care Homes model does not reflect the RACGP’s best practice model of the medical home, as outlined in the RACGP Vision for general practice and a sustainable healthcare system, released in September 2015.

The ‘biggest health reform in a generation’ did not receive extra funding from the government. I’m concerned that this is not yet the fundamental shift towards patient-focused healthcare as asked for by consumers and health professionals. What do you think?

Follow me on Twitter: @EdwinKruysDisclaimer and disclosure notice.

11 thoughts on “Why the proposed Health Care Homes are not about patient-centred care

  1. Reblogged this on Dr Thinus' musings and commented:

    Good summary that highlights a few issues about Health Care Homes:
    a. It is NOT the same as the RACGP’s medical home
    b. It is capitation which brings with it all the complexities and risks for patients and doctors while making budgeting easier for the Government
    c. It is part of the massive data mining exercise taht the Government is rolling out

    Liked by 1 person

  2. Edwin, Thanks for your analysis of what the Government’s trial offers and how it compares to the RACGP’s Vision document.

    The title of your blog post is: “Why the proposed Health Care Homes are not about patient-centred care”

    The expression ‘patient- centred care’ is as mysterious to me as the expressions ‘decision support’, ‘leverage’ and ‘roll out’. It is used daily, but I suspect that those who use it might have little idea of exactly what they mean by it, and I suspect that if you ask various people who use it, each will have a different idea of what she or he had in mind.

    The report of the jointly RACGP sponsored Roundtable on 12th July 2016 includes:

    “Patient-centred Care
    9. Develop marketing to establish clear mutual expectations and genuine shared accountability between patients and the PCHCH
    10. Implement the necessary infrastructure and build staff capability to assess care needs and deliver care through a mix of face to face, video, phone and email consultations with all the health care team
    11. Increase capacity to provide care for underserved populations
    12. Enable and support patients to be active members of the health care team”

    I wasn’t sure what point 9 means. Do we believe that ‘marketing’ alone can create ‘genuine shared accountability’ between patients and their PCHCH? What can or would make a patient ‘accountable’ to her or his PCHCH? The Roundtable report provides an answer in its expansion of point 9:

    “Accountability applies to patients as well – “giving up” the flexibility and convenience of moving from doctor to doctor in order to reap the benefits of seeing one primary health care team who support patients to proactively manage their care. Voluntary patient registration is new to the Australian context, and it is not currently known whether Australians will embrace the concept of registration. Regardless, the concept is fundamental to the patient-centred and team based approach to healthcare delivery.”

    In the government’s documents about its Health Care Homes trial, I don’t see anything that says that Medicare benefits will not be payable for services provided to enrolled patients at or by other general practices. In other words, it appears that patients enrolled in the trial will continue to receive Medicare benefits for visiting as many different practices as they wish. To me this is a failing of the Health Care Homes trial. We should note that if the system is not going to subsidise or otherwise support patients’ attendance at other practice, the enrolled practice will have an obligation to ensure availability of care, by seeing the patient when care is needed, or when this is not possible, by authorising the provision of appropriate care by other practices or health organisations.

    Point 10 seems to be partly satisfied by the statement in the Department of Health’s Health Care Homes payment information factsheet: “A bundled payment to the practice will enable flexibility in how Health Care Home services are delivered.”

    This is clearly one of the benefits of payment by capitation: it frees the practice to provide care in whatever ways that the patient and it find most efficient (while still needing to be safe and of high quality).

    Does point 11. simply ask for some extra funding or resources to enable practices to do this?

    Most of us would agree with point 12 of which I note that an important element is to be electronic access by patients to parts of their own record made by the practice.

    You conclude that the Health Care Homes trial is a capitation system. I note that your blog of February 2015 in which you reported about Dutch general practice that some of the strengths of this apparently mostly good system include:

    “GPs are now paid by insurers according to a mixed payment scheme: Partial capitation plus fee-for-service for basic care.”

    “GPs receive ancillary payments, mainly on a fee-for-service basis, for additional or special services such as care for people with chronic diseases. They are compensated on an hourly basis for care during out-of-office-hours. The incentives were negotiated with the profession and were closely aligned to professional values, which limited the risk of perverse consequences.”

    “A combination of capitation and fee-for-service in a 40/60 or 60/40 ratio incentivises effective and efficient care. A consultation should have a financial stimulus, but not too much, and at the same time the prerequisites should be there to deliver optimal care.”

    “Mandatory patient registration works well and helps GPs to coordinate care. GPs are paid to do this via an annual registration fee per patient.”

    In summary, I find the concept of ‘patient-centred care’ a rather slippery and shape changing octopus with which to grapple. Have we not always been here to serve our patients and meet their needs as best we can? I would personally ban the expression ‘patient-centred care’ along with the expressions ‘decision support’, ‘leverage’ and ‘roll out’, and replace it with more clear and more specific statements about how we can increase the accessibility, appropriateness, equity, efficiency, safety and quality of the care that we and the rest of the health system provides

    Liked by 1 person

    • Hi Oliver, thanks for your feedback. There are many ways to blend payments. In the current government’s model chronic care has been capitated. I am however glad the department scrapped the limitation of 5 visits related to non-chronic care.

      It concerns me that we’re not talking about a ‘trial’, but implementation stage 1 and that there is no ongoing conversation with the profession and consumers during the rollout. It reminds me of the PCEHR introduction – we all know about the problems and delays resulting from this unilateral approach.

      Regarding patient-centred care: we should ask our patients and consumer organisations to define this concept but I believe the current model only addresses a small proportion of the issues.

      For example, as the original RACGP vision document also reiterates: improving patient transitions between healthcare providers and silos will assist our patients stay in the community for longer, reduce the length of hospital stays and readmission rates. Most will agree that better communication and patient handover between and across sectors is required.

      There is no support or recognition of the increased resources required for GP teams providing a comprehensive range of services to their patients, no support for practices operating in socially disadvantaged areas and limited support for practices operating in rural and remote areas.

      This will need investment in primary care as well as a system-wide approach. The proposed model is certainly not the biggest health reform in a generation. It may well transform into something bigger and better in the future but, for starters, the department would do well to continue a meaningful conversation with the profession. This did happen in the example from the Netherlands you refer to.

      Liked by 1 person

      • Edwin I think you make a very important point about the subtle change in it no longer being a trial but rather phase 1 roll-out. As articulated by the RACGP present in his recent MJA talk as well.

        This point is slipping under the radar

        Liked by 1 person

  3. One wonders with all the consultations of Colleges AMA etc whether the demands placed upon our GP leaders to attend are worth the effort? I question whether there is a genuine desire to consult for improvement as opposed to appeasement.
    We throw our hands up in horror at the lack of trust and yet this is how the rest of the world operates outside of Medicine. To my mind the use of leverage is the norm anywhere but within medicine. We go into these negotiations already disarmed.
    I agree with Oliver. We have always focussed on patient centred care in traditional general practice.
    The system has now failed due to
    1. A highly mobile population.
    2. A consumeristic approach by patients.
    3. The cultural epoch of the Information Age. (Not all information is scientific )
    4. The deliberate denigration of the professions by subsequent political parties.
    5. Our inability up until now to advocate effectively.
    6 Continued denigration of the funding of Primary care such that the system is enabling aberrant physician behaviour simply to earn a living.

    We have up until now- as we re-establish the mantle of advocacy and intercession between the Gov and the coal face – only focussed that advocacy at Govt level. We are appealing to the higher nature of those only interested in the fiscal and who operate from a leverage the player consultation method.

    We need to now turn our advocacy towards the community and more widely market the nature of General Practice and it’s value.

    I do not see much point in advocating ad Infinitum with those who seek to leverage our goodwill trust and professionalism.

    Liked by 3 people

  4. There are two fundamental circumstances (I consider them facts, but might be challenged to justify them, so I will call them observations.)
    1. General practice is now considered (by public hospitals and others) to hold the clinical responsibility that the ‘general physician’ had in times past. That speciality – in practical terms – no longer exists. Public hospital emergency departments refuse to do this work. Public hospital outpatient clinics either no longer exist, or have waiting lists that are so long as to be useless. One of the roles now expected of us is to manage clinical conditions at an optimal level, that will keep the patient out of the public hospital. Every medical hospital admission is intrinsically an event of failure of general practice care.
    2. We are now expected to do this work on the present GP budget – and very shortly will be expected to do it on even less. The Turnbull government’s concept of the ‘Medical Home’ is that, with capitated payments we will – will be expected to – achieve clinically more with less taxpayer cost outlay. If we do not ‘work efficiently’, we will do significant work ‘pro bono’. Silently, without protest. The same will be true for patients with a complexity of problems ‘greater than average’. That will be our ethical responsibility. The principle has already been stated:
    “This is hard medicine and you’re going to be paid about a third to a half of what you would earn in another setting. This is not an attractive equation unless you’re particularly motivated about the reasons you get into medicine…so selling what this model is to people who would then be prepared to work in it is tough”
    That is why the ‘trial’ is being converted to a ‘roll-out’. We will have no choice.
    As Max Kamien said:
    “There is the alternative to go into general practice, but it’s much harder. To practice high-quality general practice in the current climate, to do general practice really well, you go broke.”

    Like

  5. “Patient-centred care”. Let’s just brainstorm that for a bit. Ok Mr Smith, you have diabetes and we would like to offer you a place in a chronic disease management trial. We want to provide better care for your diabetes and so we are offering you all the existing services, plus some more. You can now email me any time with a question, or call me on the phone instead of coming in. I will also be available to see you after hours if you need this. We also have a dedicated person at the surgery who can assist you with any health issues associated with your chronic condition.
    Right there, I think the patient will be signing. No need to mention the practice got $1795, from the patient’s point of view, this is great.
    So, a week into the trial, the patient rings up and says could the doctor please send a script for metformin to the chemist. Sure, no problem. [Doctor thinks, ok that took maybe 5 mins, worth $10, take that off the $1795, which is $34 a week, doc is ahead, plus that freed up a bit of time to see patients in the clinic].
    Everyone is happy.
    Roll forward 5 years. Trial is a success, everyone is included. Patient likes the system so much they call or email once a week. How many patients does each doctor have? Maybe 30,000 GPs, 22 million people, I dunno, 700 patients per GP. 5 doctor practice, $1795 per patient, 3500 patients, $6.2 million for the practice, you can bet the practice manager has signed up for that.
    And for the doctor, 700 patients each emailing once a week is 1/7th of an email per patient per day = 100 emails a day. 5 mins per email, 500 minutes, 8.3 hours. So, ok that is a day’s work, no need to see any patients. Or you can share things around in the practice, one doctor does emails, one takes phone calls, one sees some patients, practice nurse does a whole lot too without the doctor needing to be involved.
    700 patients. $1795 per patient. $1.25 million per year to answer emails all day. Hey, maybe not so bad??
    There has to be a catch. Well, ok Mr Smith now has started calling every day as he now has early onset dementia. And he wanted a home visit last night, and the email his wife sent was unanswered.
    The demand now oustrips the supply. The doctor simply has no more time left to do any more.
    Are there consequences? Does AHPRA get involved because this dodgy doctor took the cash and now doesn’t take calls or reply to emails? Does the funding get cut off?
    Or… when Mr Smith signs on at the beginning, are there some rules. One email or phone call per week, and no more. One home visit per year per patient and no more.
    The funding is capped. Can the doctor set limits and cap the care?

    Liked by 2 people

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