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.

 

We told you so: Ignoring primary care is never a good idea

Last night’s undecided election results raise many questions – and doctors will say: we told you so.

Family doctors have made it very clear during the lead-up to the federal election that it’s crucial for governments to invest in primary care to keep Australians well and out of hospital.

But not only that, during the longest election campaign in Australia’s history, GPs around the country have had discussions with millions of patients about the future of their healthcare.

Looking at the outcome of the election night, it seems that voters have taken the message to the polling booths.

Wealth should not affect our health

The day after the federal election date was announced, the Royal Australian College of General Practitioners (RACGP) launched the You’ve been targeted campaign, warning people about the looming higher out-of-pocket costs, which have already become a reality.

The aim of the campaign was not to increase health corporate profits or fill doctors’ pockets, it wasn’t even a political campaign – it was all about the message that the Australian people must be able to visit their doctor when they need to.

Doctors called on a newly elected government to invest in quality and sustainable general practice to strengthen patient services.

“Our first and foremost responsibility is to our patients,” said RACGP President Dr Frank Jones, “and this is really the message from the College in the campaign, because this is about the fact that we cannot sustain quality general practice under the present Medicare freeze.”

Posters went up in GP surgeries, messages were printed at the bottom of prescriptions, TV ads were aired and there were 2340 syndicated media stories featuring the RACGP on national TV, print and radio, and in medical and consumer media outlets across all formats.

The Australian Medical Association (AMA) followed suit and threw its weight behind the issue, and shortly after many political parties made health a key focus during the election campaign. The policy shift by Labor to lift the Medicare freeze and fund chronic disease management by general practice teams was welcomed by many.

What should happen next?

Whatever the outcome of the election will be, the new government would do well to sit down with GP leaders and develop a long-term plan to strengthen primary care. The message is simple and supported by abundant evidence: strong primary care keeps people well and out of expensive hospitals. Investing in general practice patient care pays off!

Dr Frank Jones: “The RACGP is seeking progressive health reform and a genuine commitment to the future of our healthcare system from our political leaders and we are committed to discussing funding models for a sustainable and effective primary health care system.”

As GPs around the country are moving away from bulk billing, health minister Susan Ley has already indicated she is prepared to look at a medical home model. The proposed appointment of a National Rural Health Commissioner and commitment of the Coalition to pursue a National Rural Generalist Training Pathway is another positive sign.

However, the medical home is more than a hospital avoidance project. “In a patient-centred medical home, patients have a stable and ongoing relationship with a general practice that provides continuous and comprehensive care throughout all life stages,” said Dr Jones. “This model is the most cost-effective way to address the needs of patients, healthcare providers and funders.”

There are many versions of the medical home or healthcare home. The ‘gold standard’ version is outlined in the RACGP’s Vision for General Practice and a sustainable healthcare system.

Part of the future plan should be the continuation of high quality primary care research and the introduction of non-face-to-face patient services such as video consultations to improve access to family doctors and to transform Australian primary healthcare to the digital age.

Why doctors will stop bulk billing

Patriotism is supporting your country all the time, and your government when it deserves it ~ Mark Twain.

Although federal health bureaucrats seem to think bulk billing rates will increase, about 30% of GPs say they will stop all bulk billing soon. In a previous post I explained why. As a result of government policy to freeze patient Medicare rebates, doctors are faced with three options. They can:

  1. take an estimated $50,000 pay-cut;
  2. see more patients more often;
  3. charge more.

Some will choose option 1, because they don’t want to or cannot charge their patients more, and are also unable to work more. The reality is however that most GPs will not be able to afford this option.

Others will go for option 2: they may, for example, see 7-8 patients per hour instead of 4-5. They may decide to work more days and longer hours. The question is of course: how safe is this?

Can doctors continue to offer good care when they are churning through high patient numbers? It will certainly feed the epidemic of burnout, depression and suicide among doctors and medical students.

What the Medicare rebate freeze is all about
Medicare is shaping up to be a major election topic. Still, the freeze on the patient Medicare rebate is a complex topic for many. It was a lot easier to understand when Medicare was called the Health Insurance Commission, but the principle is still the same: Medicare pays a contribution towards the doctor’s fee on behalf of the patient. Many GPs have accepted this contribution as a full payment, which is called bulk billing.
The ‘indexation freeze’ everybody is talking about means that this Medicare contribution will not be increased annually, in line with the increasing cost of living. The shortfall will have to be made up by patients which means that the out-of-pocket expenses will go up as doctors stop bulk billing. The freeze on the patient Medicare rebate was introduced by the Labour government in 2013, and will continue under a Coalition government until 2020 and possible longer. The rebate has not kept up with costs and inflation for a much longer period.

3-tier system

Then there is option 3: doctors will charge more, which will increase out-of-pocket costs for patients. As RACGP president Dr Frank Jones mentioned in this interview, we may see a 3-tier system in Australia soon:

“Dr Jones warned poorest patients would feel the impact of the freeze hardest, while there was a risk doctors would churn through appointments more quickly.

He predicted it would lead to a three-tier billing system: doctors would bulk bill their most disadvantaged patients, charge other health care cardholders a concessional rate, and private patients would be charged the Australian Medical Association’s recommended fee.”

In 2015 the RACGP surveyed GPs on how they planned to manage the patient rebate freeze. Of the 566 members who responded, the majority (57%) said they would have to increase out-of-pocket costs for patients.

GPs said they would have to do this either because the practice would stop bulk billing and begin charging a gap or co-payment (30%), or the practice would increase out-of-pocket costs for non-concessional cardholders (27%). Only 8% indicated that they would not increase out-of- pocket costs for their patients.

How fees will go up

It is to be expected that many practices will start cost-cutting: staff levels may be minimised and investments in new equipment, training & education, IT or buildings may become a lower priority. This is a risk for the quality of care.

Practices will determine a fair and equitable fee based on their increasing practice costs, professional time and services. The RACGP and AMA support GPs to set fees that accurately reflect the value of the services they offer, such as the recommended fees in the Australian Medical Association’s List of Medical Services and Fees.

Practices will review their patient demographics and billing profile and optimise the utilisation of MBS items. Pensioners and/or health care card holders may be charged an extra fee which will be much higher than the bulk billing incentive of $9.25.

Practices may decide that certain services will attract fees, for example dressings and other consumables, treating doctor’s reports, off-work/off-school certificates, phone/video consultations, data entry or certain surgical procedures.

Updating practice management software to streamline Medicare claims and EFTPOS payments may be required in some cases. Expect notices to go up in surgeries across the country to tell patients about the changes in billing policies. Unfortunately there will also be some practices that will have to close their doors.

5 reasons why the Medicare rebate freeze is bad policy

When I tweeted about the Medicare freeze last week, someone asked “Care to explain other than meaning you get less money?”

I thought it was a really good question as it highlights the complexity of the issue. Most people seem to think that it’s all about doctors’ income – but it isn’t. The Medicare rebate is also about the money patients get back from Medicare.

As we speak, around Australia GP practices are adjusting their fees as a result of the government policy. Our practice increased the fee of a basic consultation with five dollars for people without a concession card. Other practices have decided to charge a once-off $30 payment to previously bulkbilled patients.

I expect that if the freeze is not lifted these amounts will have to go up again soon.

Greedy doctors?

Everything gets more expensive over the years, including the cost of running a medical practice – think for example about rent and employing receptionists and nurses. If GP practices would not up fees, their Medicare rebate income would drop with 7.1% by 2017-2018!

Over the years more and more services will require an out-of pocket payment by patients, including pensioners and healthcare card holders. Rural doctors expect that bulkbilling in the bush will soon be a thing of the past.

But the freeze has also affected urban areas. That’s why the the RACGP and AMA have labelled the government policy a ‘copayment by stealth’.

Five arguments

The freeze is bad policy and should be reversed for five reasons:

1. Many practices will stop bulkbilling. This means higher out-of-pocket costs for patients. As a result fewer people will visit the doctor in the early stages of a disease. This will often make treatment later on more difficult, more stressful and more expensive.

2. The policy disproportionately affects disadvantaged people who cannot afford a copayment. Research shows that increased out-of-pocket costs stop people from going to the doctor.

3. The freeze undermines important Australian values such as equity of access and therefore encourages a two-tier health system.

Some argue that a copayment would cut unnecessary use of medical services. But higher out-of-pocket-costs will not weed out unnecessary visits. Many of my colleagues know that often their sickest patients will not seek medical care if it becomes more expensive.

4. Research indicates that areas with poor access to GP services have higher hospital costs. It is likely that more people will visit places where healthcare is free, such as already overloaded public hospitals and emergency departments. Dr Google will become more popular too!

5. Practices continuing to bulkbill will have to change their business model: doctors need to see more patients per hour, or practices will have to hire less staff which will affect service. Some practices will close their doors – such as Dr Adrian Jones, a Redfern GP who decided to close his practice as the margins were getting too small.

Is the freeze a necessary policy?

Medicare is not unsustainable. This is a false argument by the government. In fact, Federal Health Minister Susan Ley admitted at the national AMA conference: “The Government is not claiming we’re in a healthcare funding crisis.”

Australian healthcare performs well in comparison to other countries. The increase in health expenditure in general practice has been slow, and in line with overall economic growth and GDP.

Freezing the patient Medicare rebate will not make healthcare more efficient or reduce waste in the system.

Medicare freeze

What health consumers want: interview with Leanne Wells

Generating consumer-led ideas to improve the health system – that’s what the Consumer Health Forum is all about, says new CEO Leanne Wells. Health consumerism around the world is changing, and Leanne sees a potential for big reforms in Australia. I asked her about a range of topics, including the Medicare rebate freeze, the RACGP draft vision for a sustainable health system, funding and the role of pharmacists.

“It is a terrific honour and challenge to be leading this organisation at a time of significant developments in the role of health consumerism globally,” she says. “I believe in a strong patient-clinician alliance.”

“Consumer leadership is as important as clinical leadership in developing modern health systems that reflect the importance of patient-centred care. We can achieve this by working together to influence policy settings, design and operation of health care.”

Consumer-led ideas

What health consumers want: intervie with Leanne Wells
Leanne Wells: “Integration has to be the name of the game given modern health care is about managing multi-morbidity and complexity.”

“Our members include a diverse range of consumer organisations as well as professional associations, researchers and individuals with an interest in health consumer affairs. Through our membership network, we reach millions of Australian consumers.”

“CHF is all about generating consumer-led ideas for a better health system. It is the pre-eminent national organisation advocating on behalf of health consumers on policy issues pertaining to Medicare, PBS and population health and on issues such as health system development, access to best available consumer-centred care and access to medications.

“CHF’s work has included research and national campaigns on rising out-of-pocket health costs and prescription medicine costs. We deal frequently with questions from media on issues such as health insurance and quality and safety in health care.”

“There is potential for significant changes in Australia’s health system, particularly in Commonwealth-financed areas such as Medicare, primary health care and mental health, at a time when there are moves to put focus on reforms to Commonwealth-State health funding issues. In all of these areas, consumer-generated ideas for a better system will be crucial to success.”

Medicare rebate freeze

“CHF has supported the RACGP and others in the campaign against the rebate freeze. Nothing should compromise good quality, comprehensive, co-ordinated patient care. I support the concept of the patient-centred healthcare home.”

“Some consumers have capacity to pay a co-payment and will do so if they feel they get value. Others simply won’t go to the doctor if they are not bulk billed – and often those who don’t go to the doctor due to cost barriers are those from lower socioeconomic circumstances which we know are associated with higher rates of complex, chronic conditions: the very conditions that need ongoing, co-ordinated care. The issue highlights the need for the MBS review and a rethink of the way we finance primary care. Both are long overdue.”

“General practices need the flexibility to be truly responsive to their patient populations

“CHF seeks funding that is determined by the right models of care, not the other way around. At the moment we’ve got a system that is largely based on fee-for-service financing to drive and, at times, limit models of care.”

“General practices need the flexibility to be truly responsive to their patient populations. The expansion of health insurance to primary practice, may offer benefits in terms of better integrated care for some. The overall impact however is likely to be negative, setting up a two-tiered health system at the primary care level where insured patients would be likely to get preferential treatment.”

“The RACGP’s draft consultation paper ‘Vision for a sustainable health system’ makes the case for an alternative blended payment model offering flexibility and autonomy to respond better to contemporary care needs. The paper would be stronger if it articulated a vision for general practice emphasising how that could be done.”

“The paper lacked consideration of aspects of integrated care and placed ‘general practice’ rather than ‘the patient’ at the centre of the health system. We would have liked the paper to place greater emphasis on the patient as partner and on the consumer benefits of team-based care as well as the other non-financial levers that can work in concert to bring about change and innovation in general practice.”

Consumers as partners

“A big challenge is for health care to be much more consumer-centred. That works best when there’s a team of professionals looking after the consumer, when there’s an open flow of information and discussion between them about the patient’s needs and how to meet them together rather than separately.”

“We want to see a patient-centred approach to providing care – not disease-centred or system-centred

“Above all else patients want professionals who see them as more than just the ‘vessel’ of a disease to be cured, or a problem to be solved. Patients want to be recognised for who they are: unique individuals with their own unique lives. We want to see a health workforce which takes a patient-centred approach to providing care – not disease-centred, not system-centred, but patient-centred.”

“The National Safety and Quality Health Service Standards have consumers as partners in care as its second standard – solid recognition that this value must become inherent to the culture and operation of health services. Primary Health Networks have a pivotal role in bringing this about.”

“Having worked with divisions of general practice and Medicare Locals since the 2000s, I remain a strong proponent of the place ‘meso’ structures like these have in the system. The Primary Health Networks have great promise as disruptive innovators in our system.”

“With their distinct boundaries, alignment with hospital networks, relationship with general practice and the knowledge they will grow about their local communities, they are well placed to work with patients and clinicians to lead service and system development and innovation.”

“But they can only do this if they have mandate, the support and participation of patients and clinicians and the financial flexibility to invest in new approaches and new models of care.”

Dysfunctional state-federal funding

“The CHF supports a single level of government taking responsibility for leadership in health policy. We are diverse country with distinct regional communities. I believe moving to a single level of government, with regional purchasers administering pooled funding, is a concept worth exploring further.”

“The only way we are going to integrate the system is by having policy set nationally, and service commissioning undertaken regionally by single entities. Integration has to be the name of the game given modern health care is about managing multi-morbidity and complexity. Removing the dysfunctional nature of state-federal funding would surely be an improvement on what we have now.”

Devaluation of general practice

“Patients need to be seen as partners in care – assets not deficits. I agree that general practice and its place in the health system has become devalued over time. It is a very efficient and effective setting in which to deliver care close to where consumers live and work.”

“I applaud the RACGP’s efforts to get general practice better recognised and valued

“I applaud the RACGP’s efforts to get general practice better recognised and valued. However, in the campaign video, the doctor is represented as the sage authority while the patients are represented as passive recipients of the doctor’s view of them and their lives.”

“The characterisation was at odds with all the evidence showing that approaches which encourage patient-centred and patient-engaged care produce better outcomes. This aspect of the doctor-patient relationship could have been better reflected.”

Pharmacists and General Practice

“CHF supports a stronger role for pharmacists in general practice in areas such as medication support. It would be in the patient’s interest for general practice to have non-dispensing pharmacists as part of the team available to advise on quality use of medicines, hopefully freeing up GPs to focus on time-consuming, complex cases requiring medical expertise.”

“Expanding the scope for dispensing pharmacists to provide medical advice in pharmacies would also be supported by CHF provided the role was strictly within the pharmacist’s qualifications, was coordinated with the patient’s GP or local GP and where necessary, the services performed in a private area. Both options are good ways to make better use of an existing valued workforce.”

Patients or consumers?

“There is a continuing debate on the patient-consumer dichotomy. We prefer the use of the word ‘consumer’ when talking in terms of the health system generally. In that context we think the word consumer more accurately expresses the non-dependent status of a citizen and customer of health services and products.”

“The word ‘patient’ is appropriate when referring to an individual under treatment of a clinician where the patient’s outcome is directly dependent on the clinician.”

The Medicare freeze: A storm is coming

Health Minister Sussan Ley said at the annual AMA conference in Brisbane that the Government is not claiming we’re in a healthcare funding crisis.

At the same time dark clouds are gathering as the frustration about the patient Medicare rebate freeze rises.

The Medicare rebate is the amount patients get back from Medicare after they visit their doctor. This amount is supposed to go up every year to compensate for inflation and higher costs. The government has frozen the annual indexation for four years.

The Consumers Health Forum said in its analysis of the latest Budget: “The retention of the $1.67 billion freeze in Medicare payments to doctors may mean many patients are likely to face higher medical bills.”

The Guardian reported: “The AMA president, Brian Owler, used his opening address on Friday to call for both sides of politics to lift the ‘damaging’ freeze which could force GPs to start passing costs on to their patients, amounting to a so-called co-payment by stealth.”

And: “The federal government could face another fierce campaign from one of the nation’s most powerful lobby groups if it does not lift its freeze on doctors’ rebates before the next election.”

The RACGP has also indicated that it would consider a new campaign. It looks like we’re going to get some fireworks again.

Some common sense thoughts on health reform

When I arrived last night for a meeting with Federal MP Mal Brough, I had to work my way through TV camera crews to get to my chair.

But contrary to what everyone thought, Brough didn’t come to challenge the prime-minister. The meeting with local hospital doctors, GPs and staff was about health reform and the Medicare rebate – and what he had to say was remarkable.

I was expecting the usual: Budget crisis, rising Medicare costs, price signals etc. But this was a different message coming from a liberal MP.

Brough first showed some figures comparing (combined commonwealth and state) hospital expenditure versus GP Medicare rebates: $39.9 billion vs $5.9 billion per year. He demonstrated that hospital costs are rapidly rising but GP Medicare rebates remain more or less static.

His 3 core messages:

1. This must be a debate on improving the health of the nation, not a debate on cost cutting or cost shifting

2. A co-payment or price point should not be the starting point of this discussion

3. There are tremendous efficiencies to be had in hospital, specialist services and aged care if Primary Health provision is enhanced and is the heart of the nation’s health system.

Health organisations are hammering this message: If you want to keep patients out of our expensive hospitals, strengthen general practice – don’t take money out of the industry.

Brough underlined this by showing AIHW data indicating that over one-third of emergency department presentations were for potentially avoidable GP-type presentations (see image). A GP co-payment will almost certainly drive more traffic to the hospital EDs.

Mal Brough’s suggestion: Scrap it.

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.