WANTED: shared vision for primary care

“I do know that when primary care doesn’t connect, collaborate and work together – patients see and feel that disconnection. And I have a feeling that those working in primary care see and feel it too.

Belinda MacLeod-Smith, health consumer (BridgeBuilders.vision)

Labor’s health spokeswoman Catherine King announced that her party will create a permanent health reform commission if it wins the federal election. I thought this sounds like a step in the right direction as long-term planning of health reform is much needed in Australia.

On the other hand, there have been many government committees, task forces, reviews and reports that haven’t made a dent in the primary care landscape.

If only we could put together some of the ideas coming from Australia’s health and consumer groups. These organisations, often working at the coal face of primary care, have an excellent understanding of the urgent needs and requirements. 

I was pleased to see that some of this year’s pre-budget submissions by primary care organisations contain similar ideas. For example, the pre-budget submissions from AMA, ACRRM and RACGP all argue for funded telehealth services.

As expected, there is a strong push for adequate patient Medicare rebates and reduced patient out-of-pocket costs. The general practice profession also believes that spending more quality time with patients should be encouraged through better remuneration of longer consultations. 

One of the main themes is improving care for people living with chronic and complex conditions. The Australian Medical Association is proposing a chronic disease quarterly care coordination payment to GPs to support team-based care. 

The Royal Australian College of General Practitioners is advocating for comprehensive reform that includes blended funding, based on the Vision for general practice and a sustainable healthcare system.

The Pharmaceutical Society of Australia wants pharmacists in residential aged care facilities. The Consumers Health Forum argues for an Australian Co-Creating Health initiative to support people with chronic conditions to actively manage their own health.

Rural doctors, RDAA and ACRRM, are asking for more junior doctor training places in rural and remote settings and a move to the rollout phase of the National Rural Generalist Pathway.

This is just a selection of some of the budget submissions. What struck me is that there is a lot of merit in many of the proposals. They are often not mutually exclusive.

Unfortunately, most budget submissions seem to end up in a large pile on the minister’s desk. Many great ideas never see the light of day, because there is no sector-driven vision or strategy.

Is this the best we can do? I believe it is time to work towards a shared vision for primary care. Why not start by looking at what the various organisations and groups have in common?

MBS Review: A stronger primary care system in sight?

Implementing healthcare reform in Australia is always an uphill battle. After a disappointing outcome of the much-anticipated Healthcare Homes program, some of the members of the Primary Health Care Advisory Group regrouped when they were appointed to the Medicare Benefits Schedule (MBS) Review Taskforce.

The recommendations by the taskforce to improve the MBS are refreshing in many ways. There is a move towards strengthening GP stewardship, voluntary patient enrolment, more non face-to-face care, a simpler careplan program and increased support for home visits – which seems sensible and is addressing the frustrations of many about the current Medicare system.

It appears there are a few things missing. For example, there is no recommendation to spend more time with our patients by committing to an increase in the schedule fee of longer consultations (item numbers 36 and 44). This would have been more useful for most patient encounters than a new one-hour plus item number.

I believe the residential aged-care item numbers will need more investment when the SIP incentive ceases to exist. There is mention of outcome-based payments which requires an explanation. The lack of detail about the dollar values makes it challenging to predict the impact on general practice and primary care.

In an ideal world the recommendations could result in an invigorated, modern, patient-centred health system. However, if history repeats itself, the result will be a simple cost-saving exercise, dressed up as clinician-led, evidence-based healthcare reform.

A typical case of make it or break it.

The family doctor – old-fashioned or the key to a healthy future? (Part 2)

Is the family doctor who provides ongoing care a thing of the past? Not really.

In part 1 I mentioned the three types of continuity of care: informational, management and relational continuity. Continuity in primary care results in improved patient health outcomes and satisfaction. Evidence also shows that primary care, in contrast to specialty care, is associated with a more equitable distribution of health.

Receiving care from one general practitioner is beneficial for a variety of health outcomes. For example, relational continuity reduces both elective and emergency admissions. In other words, the rate of hospital admissions drops when people have their own GP.

6 mechanisms that improve our health

Primary care researcher Barbara Starfield identified six mechanisms that, alone and in combination, may account for the beneficial impact of primary care on population health:

  1. Primary care increases access to health services for relatively deprived population groups
  2. The quality of clinical care by primary care physicians is at least similar to specialist care for specific common diseases
  3. The positive impact of primary care on prevention
  4. The beneficial impact of primary care on the early management of health problems
  5. The accumulated contribution of primary care characteristics to whole-of-person care
  6. The role of primary care in reducing unnecessary or inappropriate specialty care.

Barbara Starfield
Barbara Starfield: “(…) good primary care is associated with better health outcomes, lower costs, and greater equity in health.” Source: Wonca

Starfield: “There is now good evidence, from a variety of studies at national, state, regional, local, and individual levels that good primary care is associated with better health outcomes (on average), lower costs (robustly and consistently), and greater equity in health.”

General practice can deliver long-term, cost-effective continuity of care. A visit to the GP is on average ten times cheaper than a visit to the emergency department. Dr Sebastian Seidel mentioned at a Senate Inquiry last month that GP services in Australia cost taxpayers only $250 per person a year – cheaper than car insurance.

In Australasia, chronic conditions account for about 85% of the total burden of disease, and in 9 out of 10 deaths a chronic disease was a contributing factor.

Unfortunately there is currently inadequate support for the continuity of care required to improve outcomes for patients with complex or multiple chronic conditions and comorbidities.

The Australian government is developing a National Strategic Framework for Chronic Conditions and recently, the Primary Health Care Advisory Group has investigated options into the reform of primary health care to support patients with complex and chronic illnesses. The group’s reform paper is complete and handed to the Federal Health Minister. It will be very interesting to see what happens next.

Conclusion

Although I am more than likely biased, it is obvious to me that primary care has a lot to offer. Continuity of care by general practitioners and their teams has many proven benefits as outlined in part 1 and part 2 of this blog post series.

GPs see about 85% of Australians each year but general practice spending represents less than 8% of the overall government healthcare budget. What we need is better aligned funding that supports primary care practitioners to deliver long-term quality care.

A sustainable health system should free up GP teams and other health practitioners to deliver coordination and integration of care across disciplines, especially for people living with complex and chronic health conditions. Looking at the reform processes that are under way in Australia, we may be getting closer to a better and more sustainable solution.

Integrated health services, what do you mean?

It has been described as the holy grail of healthcare: the patient at the centre and the care team working seamlessly together, no matter where the team members are located, what tribe they belong to or who the paymaster is.

Integration has been talked about for many years. The fact that it’s high on the current political agenda means that there’s still a lot to wish for. Although we have high quality healthcare services, our patients tell us that their journey through the system is everything but smooth. Most health professionals are painfully aware of the shortcomings in the the system.

What is integration?

So what do we mean when we talk about integration? Co-location of health professionals? Team meetings between doctors, nurses and allied health professionals? Hospital departments talking to each other? Communication between GPs and specialists? Working across sectors? Packaging preventative and curative services? Patient participation? One electronic health record? A shared management and funding system?

Integrating health services means different things to different people. For that reason the WHO proposes the following definition:

“Integrated service delivery is the organisation and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money.

Integration is a means to an end, not an end in itself. Sharing resources may provide cost savings but, says the WHO, integration is not a cure for inadequate resources. Obviously, integrating services doesn’t automatically result in better quality. It’s also worthwhile noting that co-locating services does not equal integration.

There is a difference between integration from a consumer point of view, which often implies seamless access to services, and professional integration, which is achieved through mixing skills and better collaboration. These two types of integration don’t necessarily go hand in hand.

So it is useful to ask: what problem are we trying to solve? Are we trying to improve the patient journey through the health system? Do we want to support health professionals to deliver better care? Or is the main driver government concerns about costs?

How to achieve it?

One thing is certain: we must fight fragmentation. This is challenging as we are seeing a wave of commercially driven, disruptive services appearing in the healthcare sector. These solutions may be attractive to consumers because they are convenient, but they usually don’t contribute to a better or more integrated health system.

Unfortunately the evidence around integration is limited, but the authors of this MJA article are suggesting a way forward. They have looked at international health reform initiatives improving integration between community and acute care delivery, and they found that the following 10 governance elements are essential to support integration:

  1. Joint planning. Governance arrangements included formal agreements such as memoranda of understanding
  2. Integrated information communication technologies
  3. Effective change management, requiring a shared vision
  4. Shared clinical priorities, including the use of multidisciplinary clinician networks, a team-based approach and pathways across the continuum to optimise care
  5. Aligning incentives to support the clinical integration strategy, includes pooling multiple funding streams and creating equitable incentive structures
  6. Providing care across organisations for a geographical population, required a form of enrolment, maximised patient accessibility and minimised duplication
  7. Use of data as a measurement tool across the continuum for quality improvement and redesign. This requires agreement to share relevant data
  8. Professional development supporting joint working, allowed alignment of differing cultures and agreement on clinical guidelines
  9. An identified need for consumer/patient engagement, achieved by encouraging community participation at multiple governance levels
  10. The need for adequate resources to support innovation to allow adaptation of evidence into care delivery.

Major paradigm shift

The first thing we need is a shared vision. A major paradigm shift towards more integration requires motivated and engaged stakeholders and champions, a shared sense of purpose and a culture of trust. This should be established before embarking on a new journey. We must avoid making the same mistakes that have caused so much havoc in projects like the PCEHR.

It will be a challenge to get health professionals to focus more on coordination instead of daily care delivery. An essential step here is to increase capacity. The last thing we need is an overloaded primary care sector such as in the UK. The RACGP is suggesting an overhaul of primary care funding to faciliate integration and coordination. Similar changes will be required to free up hospital doctors to e.g. discuss patient cases with primary care providers.

The big question is: who will take the lead? It is likely that a lot of  work will happen at a local level and primary health networks could play a crucial role here. A shared agenda, clear goals and genuine stakeholder involvement are keys to success.

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

Minister, please don’t ruin our holiday again

Before Christmas – just as I was about to pack my suitcase – Prime Minister Tony Abbott dropped a bomb.

Together with the Health Minister he announced that the Government had introduced a policy to stop 6-minute medicine – or ‘sausage machine medicine’ as he called it. As a result the Medicare rebate would be reduced in January by $20 for GP consultations of less than 10 minutes.

Battle won, but not the war

This cut to Medicare patient rebates was meant to deliver $1.3 billion in savings over four years. However, as a result of the backlash by GPs and health consumers, the proposal has now been scrapped.

The other 2 components of the Government’s revised co-payment plan are still on the table: $873 million saving from a $5 Medicare rebate cut, and $1.3 billion saving by a four-year freeze of Medicare fees for GPs, medical specialists, optometrists, and others.

Expect more fireworks in the coming months.

6-minute medicine

Was Abbott right about the sausage machine? Are bulk-billing doctors churning through patients in six-minute sessions?

Most GPs felt Abbott’s argument was a sham as the issue was never raised in the budget. The real agenda was obviously to save health dollars. The timing – just before the Christmas break – as well as the one month’s notice before the measure would kick in, added insult to injury.

Some said it was a case of attempted political suicide.

Research shows that the average GP consultation lasts 14 minutes, not six. Some consultations may only take 5 or 6 minutes, but that’s not necessarily a bad thing. Here’s an example:

Someone comes in with a painful wrist after a fall. An efficient, experienced GP can take a history, examine the wrist and, if needed, organise further investigations within 6 minutes. The GP-in-training may take 20 minutes to do the same, should she be paid more? Probably not.

Abbott’s argument is of course not coming out of the blue: ‘6-minute medicine’ has a bad reputation because some business models of larger corporate GP clinics are purely profit-driven, and it is thought that this can lead to a high patient-turnover.

If Abbott has a problem with this practice, his Government should deal with those clinics, and not punish all GPs and their patients. But there’s more to it.

The real problem

The real problem is the increasing gap between the Medicare rebate and the costs of running a practice. While business expenses are going up every year, Medicare has only slightly increased the rebates over the years – barely covering inflation, and for the past 1.5 years the rebate has been frozen.

As a result, doctors need to see more patients per hour or work more hours, if they want to continue bulk billing. Another option is to retire (not recommended). Or they can choose to charge a gap fee or co-payment. This has happened before.

In 2003 bulk billing rates were at an all-time low of 66%. This didn’t make the Howard Government very popular, so the health-minister – Tony Abbott – had to increase the Medicare rebates. As a result, bulk billing went up again.

The solution

At the moment bulk billing rates are at an all-time high, about 85%. If the planned $5 rebate cut and freeze per the 1st of July 2015 go ahead, it is likely that less clinics can afford to bulk bill. History tends to repeat itself: If voters start to complain at a level of about 66% the Government may feel there is room to play – that is if they can get their proposals through the senate.

The new Health Minister Sussan Ley indicated after the backdown last week that she will continue to look for ways to make Medicare ‘sustainable’ and introduce a price signal by way of a co-payment. At the same time she wants to protect bulk billing and maintain and improve high quality healthcare.

I just hope that whatever the solution will be, private insurers are kept at a distance.

It’s good to hear that Minister Ley will talk to doctors – she seems genuine. Many GPs have already started the debate about ways to cut red-tape and increase efficiency in primary care. I’ve heard some excellent suggestions.

A bottom-up approach to health reform takes longer, but is more likely to succeed.