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

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.

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

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.

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?

An opportunity for the Government to develop a real health policy

“Health policy has proved, over the years, to be a bugbear for the Liberal Party. The Fraser Government had made numerous changes to its health policy, which had been both unsettling and politically damaging” ~ John Howard in Lazarus Rising

As they say, those who cannot remember the past are doomed to repeat it. Governments often make two mistakes when it comes to health policies:

  1. It is driven by dollars instead of health outcomes
  2. Advice from patients and health professionals is ignored

The current ‘health’ debate has, in reality, been a debate about the level of out-of-pocket expenses. The elephant in the room – more efficient funding – has been carefully avoided. We know there is too much waste and bureaucracy in the system – and many have argued the fee-for-service model is not ideal to manage chronic health problems.

If the Abbott Government is serious about tackling some of these issues, but wants to avoid the mistakes of the past, they should embrace the RACGP’s draft Vision for a sustainable health system. It is an opportunity to start a real healthcare debate.

The new model

As the draft document reiterates, health systems focusing on primary healthcare have lower use of hospitals and better health outcomes when compared to systems that focus on specialist care. It makes sense to fund a comprehensive range of services in primary care, based on local community needs.

The new vision proposes voluntary patient enrolment with a preferred practice to improve chronic care delivery and funding. It also recommends that current incentive payments are replaced by a payment system that facilitates the following five key activities:

  1. Better integration of care
  2. Supporting quality, safety and research
  3. Team-based nursing care
  4. Using IT and e-health to improve efficiency
  5. Teaching students

Acute care and fee-for-service are still part of the package, but practices and GPs delivering ongoing comprehensive and complex care will be better rewarded in the new model. It will also assist practices and doctors looking after disadvantaged patient populations.

Much needed leadership

Earlier this year the RACGP invited members to comment on a first draft. Yesterday RACGP president Frank Jones presented the current version to Federal Health Minister Sussan Ley. It’s good to see the RACGP welcomes further feedback. Personally I am particularly interested in the response from patients and consumer organisations.

It seems the blended payment model reflects the increasing focus on chronic disease management, while still rewarding acute care. As always, the devil will be in the detail. But to be fair, this is a draft (and if you ask me, a good one).

By starting the discussion the RACGP is showing leadership. Let’s hope the Federal Health Minister is appreciative and brave enough to take on the challenge.

Revised payment model
Revised payment model as suggested by the RACGP: The model blends fee-for-service with practitioner support and practice support payments. Source: RACGP