Can we deliver high value care with one eye on the clock and the other on the screen?

Given longer consultations are associated with better health outcomes, the Medicare Benefits Schedule should be restructured to incentivise appropriate consultation time in general practice.

It is estimated that doctors are making an incorrect diagnosis in up to 20% of cases, and up to 30% of investigations may be unnecessary. It is often thought that medical knowledge and skills are the culprit, but there is another reason for the majority of medial mistakes.

Doctors need time to listen and think. General practice’s inherent time pressures, interruptions and the need to record information on computers can be distracting and cause cognitive errors. Our thinking process is also influenced by our emotions; for example, as a result of work stress or running late.

This is not rocket science and has been well documented. For example, in his New York Times bestseller, How doctors think, Harvard professor Jerome Groopman described how snap judgments and other cognitive errors by doctors can lead to medical mistakes.

In a television interview, Professor Groopman explained how over the years the consultation time gradually had to drop from 30 minutes to about 12 minutes. A doctor can’t think, he said, with one eye on the clock and the other eye on the computer screen.

Increasing complexity

In Australia and New Zealand, chronic conditions account for 85% of the total burden of disease, and a chronic disease is a contributing factor in nine out of 10 deaths. The increasing multimorbidity and complexity of care requires that doctors spend more time with their patients. Managing several medical and psychosocial problems in a 15-minute consultation is increasingly challenging for doctors and many patients.

It is not surprising that longer consultations seem to be associated with better patient outcomes. The benefits of extended consultations of 20 minutes or more for certain patient groups have also been explored overseas. More time with patients may lead to higher patient satisfaction, fewer errors and a lower volume of prescriptions, investigations, referrals and hospital presentations.

It is time to slow down. At the moment, the Medicare Benefits Schedule (MBS) fails to recognise this growing problem as it encourages throughput. For example, seeing patients in blocks of four 15-minute appointments per hour is valued at $148.20, but two 30-minute consultations per hour is worth a total of $143.40.

Health Care Homes

Is block funding such as proposed in the Federal Government’s Health Care Homes model encouraging more time with patients? Probably not. In fact, one could argue that it incentivises less face-to-face time with the GP and more contact with nursing staff and other team members.

Our patients deserve our time. The MBS schedule could support our patients with chronic and complex health conditions by better rewarding longer GP consultations.

This article was originally published in newsGP.

Health of the Nation: good and bad news according to Australia’s GPs 

Australia’s GPs believe that mental health is the number one emerging health concern, often related to co-existing chronic health conditions – but more is needed to keep Australians well.

This is one of the conclusions presented in the benchmark report General Practice: Health of the Nation 2017 which gives a unique overview of the general practice sector.

The report is based on various sources, including research commissioned by the Royal Australian College of General Practitioners (RACGP) and the MABEL (Medicine in Australia: Balancing Employment and Life) Survey.

Some of the key messages from the report:

  1. Mental health is today’s biggest health problem and will continue to be an issue in the future
  2. The GP is the most accessible health professional and should be utilised to keep Australia well
  3. Patient out-of-pocket expenses in general practice are increasing and present a barrier to patients accessing the required care

The bad news

GPs report that psychological issues such as depression, mood disorders and anxiety are the most common health issues they manage. Mental health was flagged by RACGP members as the health issue causing most concern for the future, followed by the often related problems of obesity and diabetes.

GPs believe that mental health and obesity are two key health policy issues the Federal Government should prioritise for action.

From the benchmark report: “This is a clear warning of both the current frequency and future potential impact of psychological ailments on individuals, the community and the broader health sector. It is also a stark reminder that the personal and financial health costs associated with obesity and diabetes are expected to escalate.”

However, the number one health policy issue flagged by GPs is the problem of the low patient Medicare rebates. GPs have indicated this requires immediate Federal Government action to make sure that access to high quality healthcare is maintained.

As the cost of providing high-quality health services and running general practices continues to rise, GPs are finding it more difficult to bulk bill patients. Between 2013-14 and 2016-17 the growth of the bilk billing rate has slowed down.

Patient out-of-pocket contributions continue to increase each year as Medicare rebates fall further behind the real cost of providing general practice services.

The good news

Most Australians can see their GP when they need to. Nearly all patients (99.3%) report that they are able to see a GP when they need to and most people are able to get an appointment for urgent medical care within four hours.

Australians access GPs more than any other part of the health system. They report that they visit their GP more than they receive prescriptions, have pathology or imaging tests, and see non-GP specialists.

Eighty-three per cent of patients report that they visit their GP multiple times a year, including 11% who report seeing their GP 12 times or more. The availability of GP services has further increased with extended opening hours.

GPs coordinate care within multidisciplinary teams and Australians report positive experiences with their GP.

More time with patients

The RACGP is arguing for Medicare changes that will incentivise doctors to spend more time with patients – by increasing the patient rebate for longer consultations.

RACGP President Dr Bastian Seidel said: “We believe when GPs are spending more time with their patients, that leads to less prescribing, less pathology, less referrals, enhanced continuity of care, and that would, of course, mean less hospital presentations as well.”

General practice accounts for less than 9% of total government recurrent expenditure. The RACGP, AMA and other groups believe this is inappropriate as more health benefits for Australians can be gained by investing in primary care.

 

Download the report here.

 

Promising breakthrough: dramatic miracle cure offers hope to victims

The problem with headlines about medical breakthroughs and miracle cures is that they never live up to the expectations. On the other hand, the breakthroughs happening every day in primary care do not attract much media attention.

Seventeen years ago medical journalist professor Schwitzer published the seven words you shouldn’t use in medical news: ‘promise’, ‘breakthrough’, ‘dramatic’, ‘miracle’, ‘cure’, ‘hope’ and ‘victim’. Has Schwitzer’s taboo list made an impact?

Words you shouldn't use in medical news
Source: Twitter

Not really. A quick Google search shows that the same words are still used to celebrate ‘heroic medicine’ – often surgical interventions, new drugs or medical technologies. Scientific progress and developments are important but not always easily translated to every day care for every day Australians. They are never ‘miracle cures’.

At the same time we are seeing an increase in spending on hospital treatments but little investment in keeping Australians healthy and out of hospital. Although the breakthroughs in primary care are not regarded as newsworthy, they are often life-changing.

Dramatic & miraculous examples

Here are some of the amazing health ‘breakthroughs’ that are happening every day in Australian communities:

The patient who, supported by her general practice team, feels so much better after getting control of her diabetes. The person with a mental health condition who, after many months of hard work, and treatment by his psychologist and GP, is able to do the groceries again without a panic attack.

The woman who died peacefully at home, according to her wishes with close family around and supported by her GP and the palliative care team. The obese man who has been able to lose weight as a result of determination and regular contact with his GP and allied health team.

The patients who were glad they came in for a blood pressure check or immunisation because the general practice team picked up a heart murmur or melanoma. The highly anxious child who returned to school with help from the multidisciplinary team – much to the relief of the parents.

Medical news: wrong headlines
News headlines: room for improvement?

 

The courageous person who opened up and told his GP or practice nurse what he has never shared with anyone else before – and made a start to change his life. The worried parents demanding antibiotics for their feverish baby, but eventually leaving the GP practice relieved and without a script because they know the infection is self-limiting.

The hospital admissions avoided through a phone call by the GP – with a concerned patient, allied health professional, aged care facility nurse or hospital doctor. The elderly, isolated and malnourished patient who improved and continued to live independently with support from community nurses and the general practice team.

The consultation around the plastic bag of medication boxes brought in by a patient after a visit to the hospital – an essential chat about which tablets to take and when, to make sure she gets better.

Promising breakthroughs

Professor Lesley Russell Wolpe wrote in Inside Story about the value of incremental care. She said: “Heroic medicine has its place, but treating it as the core of medicine means that the majority of government funding goes to hospitals, acute care and elective surgery, a situation that is reinforced by the political imperative to deliver visible returns in a short election cycle.”

She said: “Treating general practice as a speciality in its own right — along the lines of the current advertising campaign ‘I’m not just a GP. I’m your specialist in life’ run by the Royal Australian College of General Practitioners — would help. Ensuring that primary care has the resources to keep up with its central role in the healthcare system is also vital.”

In the years ahead more ‘dramatic breakthroughs’ will continue to come from primary care teams who, day in and day out, assist people with important health decisions and adjustments in their lives. It is time to change the headlines. It is time for decision-makers to increase their support for primary care.

As RACGP president Dr Bastian Seidel said in The Australian: “Our patients want health, they don’t necessarily want treatment”.

Health Care Home for sale?

The government seems to have lost the goodwill of the profession about their Health Care Homes model. On Friday afternoon the details of implementation stage 1 were published and it was underwhelming – to say the least.

A health reform like this, which should focus on better integration, coordination and team care, must be planned and rolled out in collaboration with the profession and consumers, not quietly published on a Friday afternoon.

Despite initial reassurances from Federal Health Minister Sussan Ley, there has been no consultation. Many GPs have expressed concerns during the weekend or indicated that they have lost interest in the model.

Restricted Medicare access

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.

Several details of the government’s proposed model, including the risk stratification tool, are not yet available. What happened to support for multidisciplinary team care, comprehensiveness loading (incl for rural and remote areas) and realigning PIP and SIP funding?

Under the model support payments for chronic disease management will be bundled, with enrolled patients eligible for only 5 non-chronic disease related services per year. Restricting access to acute care for people with chronic and complex conditions is not helpful and puts patients at risk.

Underfunded trial 

RACGP president Bastian Seidel said: “At best, it is a two year underfunded trial on the effects of inadequate capitation funding. It will put financially vulnerable patients at risk of not having access to Medicare rebates when they seek care that is not associated with their predetermined chronic health condition.”

It is difficult to comprehend that the government acknowledges there is a growing problem with regards to Australians living with chronic & complex conditions, it wants major reform to tackle this issue but is not prepared to invest in a sustainable, evidence-based and cost-saving model supported by the profession and consumers – and does not consult.

The proposed model is inadequately funded and will likely fail to improve health outcomes for Australians living with chronic and complex health conditions. I’m sure the government can do better than this.

The baby, the bathwater and a better health system

A better health system
Image: Pixabay.com

So we have a healthcare funding problem. Although there seems to be an appetite for change, it’s essential not to throw the baby out with the bathwater.

Our fee-for-system hasn’t done a bad job. Australians are healthier and live longer compared to many other countries, and our primary care sector is delivering cost-effective care.

On the other hand, as a result of population ageing, advanced technologies and new treatments, care becomes more expensive. Care needs are increasingly complex and require more interventions by a larger number of health professionals.

Our current fee-for-service may not be the best funding model for people with chronic and complex health problems, as it does not reward certain aspects of care – such as coordination.

The Federal Government is aiming for a ‘healthier’ Medicare and intends to find better ways to look after people with complex and chronic diseases, and keep people out of hospital longer. As part of this strategy the Primary Health Care Advisory Group (PHCAG) has been established to advise the government on reforming primary health care.

The PHCAG recently released a discussion paper and individuals, peak bodies and consumer organisations have responded with submissions. The advisory group’s recommendations for government are expected by the end of the year.

The future vision

The Royal Australian College of General Practitioners has, after consultation with members and external organisations, developed the ‘Vision for general practice and a sustainable health system’. If implemented, it will keep the benefits of fee-for-service for acute care, while improving care for people living with chronic and complex health problems.

The current Medicare Benefits Schedule discourages GPs from spending the time required with patients who have chronic and complex health issues. The system is based on face-to-face contact with patients – while care coordination and teamwork does not always involve the physical presence of the patient.

Consumers would like to see a healthcare model that empowers patients; they want less fragmentation and better integration and coordination of care.

To solve these issues, the RACGP made a range of recommendations in its submission to the PHCAG, based on the freshly developed vision. Essential components of the submission are voluntary patient enrolment and, in addition to the fee-for-service model, the provision of supplementary funding to support a range of patient services not currently or appropriately recognised.

Benefits of the medical home

Voluntary patient enrolment for all patients – not just for those with chronic and complex health conditions – ensures enduring relationships between patients, their personal GP and extended healthcare team, allowing for better targeted and effective coordination of clinical resources to meet patient needs.

There are four main benefits of voluntary patient enrolment:

  1. Practices will have a better understanding of their patient population and can better tailor services to the needs of their community.
  2. A stable and enduring relationship between a patient and a GP has a positive impact on health outcomes.
  3. It will benefit prevention and management of chronic diseases.
  4. Linking chronic disease management Medicare item numbers to a patient’s medical home will make sure funding for chronic disease management is directed efficiently and effectively.

Patients may choose whether or not to enrol in a medical home. Likewise, GPs and practices may choose to participate in the program.

Patients will be able to access standard consultations through any general practice, but chronic disease management, integration of care and preventive health will be limited to their medical home.

Implementing the medical home will need both initial and ongoing investment. However, any investment will result in cost savings, as efficiencies in the system are achieved.

New funding models

The introduction of support for GPs and their teams to undertake coordination work on behalf of their patients is essential and will stimulate multidisciplinary teamwork. This includes direct and efficient (electronic) communication between providers, and GPs need to be able to delegate care coordination responsibilities within a team.

A comprehensiveness payment made to a practice would recognise the practices and practitioners that offer a broad range of services to the community. The payment would be based on a defined breadth of item numbers used within a defined time.

The current incentives (PIP and SIP) need to be replaced by practitioner support and practice support payments as outlined in detail in the RACGP vision.

Reporting of de-identified patient data can be useful for the purposes of informing health system planning, but the college does not support the reporting of individual patient’s health outcomes or a pay-for-performance system. There is no evidence to suggest that reporting health outcomes improves the quality or safety of care, and there are no successful overseas models that can be adopted.

The cost of delivering quality care within the general practice setting is significant and increases annually in line with wages, consumables and infrastructure costs. It is imperative that Medicare patient rebates keep pace with the increasing costs of delivering quality care, so the freeze on Medicare rebates must be lifted.

General practice in Australia delivers efficient and cost-effective care. It is clear that health systems focusing on primary care have better health outcomes and lower use of hospitals. Now is the time to strengthen primary care – but let’s not throw the baby out.

This article was originally published in The Medical Republic.

Follow me on Twitter: @EdwinKruysDisclaimer and disclosure notice.

The receptionist will call the wheelchair taxi for you now

Wheelchair
Image: Pixabay.com

“Doctor can I talk to you about something else?”

“No.”

“…what do you mean?”

“It’s not allowed. We have just finished your care plan. The government does not want me to see you for something else on the same day. They call it double dipping. Please come back tomorrow. The receptionist will call the wheelchair taxi for you now.”

Further reading: Budget 2013-14: Medicare Benefits Scheme – removing double billing