Disruption by the after-hours industry and why you should care

After-hours medical home visiting services are important for patients and their doctors but we need an ethical and sustainable model that integrates with day-time services.

Doctors and professional medical bodies including the RACGP and AMA regularly express concerns about healthcare models that compromise on quality, fragment and duplicate care or fail to use scarce health dollars efficiently.

The Medicare Benefits Schedule (MBS) Review Taskforce has voiced similar concerns in relation to some of the home visiting services. In its recently published interim report the taskforce notes that the growth in claiming of urgent attendances by after-hours medical services is showing an increase far in excess of population growth.

The taskforce believes the services often interfere with continuity of care by the patient’s regular GP and represent low value care. It is not convinced that the rise of urgent after-hours home visits has had a significant impact on hospital emergency department services.

Inappropriate use of funding?

Indeed, there are indications that funding for after-hours medical services in the community may be used inappropriately. For example, I have received reports from some of these services delivering repeat prescriptions after-hours to patients’ homes. The care is often not provided by GPs but by less qualified practitioners.

An after-hours visit classified as ‘urgent’ attracts a Medicare rebate which can be $100 more compared with the same service provided at a GP practice. This has created a lucrative standalone after-hours industry which doesn’t always represent value for money for the taxpayer.

No reduction of emergency department presentations
The assumption that increased provision of urgent, after-hours consultations (MBS item 597) would reduce demand for emergency departments has not been confirmed. Source: AFP

Let’s look at the ACT: since the arrival of the bulk-billing National Home Doctor Service in the capital, home visits rose from 1588 in 2013–14 to 20,556 in the previous financial year.

According to the Medicare Benefits Schedule Review Taskforce, Medicare benefits paid for urgent after-hours services have increased by 170 per cent, from $90.8m in 2010–11 to $245.9m in 2015–16, whilst benefits paid for normal GP services increased by 27 per cent.

There is no reasonable explanation for the exponential growth. The taskforce is of the opinion that MBS funding should continue to be available for home visits in the after-hours period but has made some sensible recommendations to improve the model.

After-hours lobby 

The response from the after-hours lobby speaks for itself: The National Association for Medical Deputising Services started an aggressive lobbying campaign to ‘protect home visits’.

Although several after-hours services left the corporate lobby group – including the Canberra After-Hours Locum Medical Service, the Melbourne-based DoctorDoctor service and the Western Australian Deputising Medical Service – the campaign continues to target consumers and politicians.

The actions of the lobby group and some after-hours services have raised eyebrows. Mass media advertising and marketing campaigns via television, newspapers, and billboards will drive unnecessary use and should be avoided. Similarly bookings for after-hours deputising services during daytime hours should stop.

A sensible solution

It’s not rocket science: As after-hours home deputising services do not offer comprehensive GP care, they should only be used when a patient’s usual GP or general practice is not available and the patient has a health concern that cannot wait until the following day.

It is time to use these Medicare-funded services wisely – when genuinely needed, not wanted or promoted.

Health Care Homes: not yet where the heart is

Doctors have called on the Federal Government to delay the implementation of the Health Care Homes model from the current starting date of 1 July 2017 by at least three to six months. Here’s why.

United General Practice Australia, which comprises the leading general practice organisations RACGP, AMA, RDAA, GPSA, GPRA, ACRRM and AGPN, has serious concerns regarding capitated funding for chronic disease management and treatment. It may harm patients, and it may undermine GP-led care when funding runs out.

Additional time to plan for the Health Care Home model is required to get the nation’s healthcare system right and properly consider, design, and implement the supporting tools, information and adequate funding mechanisms.

The extended timeline would allow stakeholders time to ensure the instruments and tools being used are appropriate and validated by evidence.

Health Care Homes: the background

A Health Care Home (HCH) is not a place but a partnership between a patient, their GP and the primary care team. Health Care Homes are general practices and Aboriginal Community Controlled Health Services that coordinate the ongoing comprehensive care of patients with chronic and complex conditions.

As part of the 2016-17 Federal Budget, the Government announced the Healthier Medicare: Reform of the Primary Health Care System package. The core element of the package was the staged rollout of Health Care Homes in selected Primary Health Network regions starting in July 2017.

The Government has re-directed $21.3 million from the Practice Incentive Program and is redirecting a further $93 million in MBS funding to support the HCH trial.

HCHs have the potential to drive a fundamental shift in Australia’s health services toward patient-focused health care practices and are a modified version of the Patient-Centred Medical Home (the Medical Home).

The HCH aims to facilitate a partnership between individual patients, their preferred GP, and the extended healthcare team. The model should enable better-targeted and effective coordination of clinical resources to meet patients’ needs.

Patient-centred Medical Homes have been associated with increased access to appropriate care and decreased use of inappropriate services – particularly emergency departments – for patients with chronic and complex conditions.

The clinical team– which may include GPs, nurses, nurse practitioners, Aboriginal health workers, care coordinators, allied health professionals and other medical specialists – collectively provides care for patients.

The HCH aims to meet as many of the patient’s healthcare needs as possible and for collaborating with other health and community services.

In the current proposal Health Care Homes will receive monthly ‘bundled payments’ on a per patient basis, depending on each eligible patient’s level of complexity and need. The payments will be paid to the Health Care Homes, not GPs.

All general practice healthcare associated with the patient’s chronic conditions, previously funded through the MBS, will be funded through the bundled payment. Regular fee-for-service will remain for routine non-chronic disease-related care patients.

Funding for services provided by allied health professionals and specialists, as well as for diagnostic and imaging services are not included in HCH bundled payments and will continue to be funded through the MBS.

Stage one is limited to Medicare-eligible patients with two or more complex or chronic conditions. Patients that fall within three identified tiers will be eligible to enrol in a Health Care Home.

The Department of Health is developing a patient identification tool to be used by HCHs to identify eligible patients as per the tiers. The Department states that the tool will attribute a risk score to each patient, which will determine the level of care required and subsequently the value of quarterly bundled payments that HCH will receive.

Unfortunately details on the eligibility assessment tool have not yet been released, but will likely draw upon information the practice already has on the patient (for example previous hospital admissions, diagnosis, medications, clinical risks), as well as non-clinical information such as demographic and psychosocial factors.

The patient identification process will be the same across all stage-one HCHs, regardless of whether or not they are in rural and remote areas.

The Practice Incentives program (PIP), a key driver of quality care in general practice, is currently undergoing reform. The redesigned PIP program will reportedly introduce a quality improvement incentive to replace the clinical specific incentives in the current PIP and provide a ‘flexible and supportive structure to the HCH implementation’.

Stage one of the implementation is currently set to commence on 1 July 2017 and run for two years until 30 June 2019. It will involve approximately 65,000 patients and up to 200 general practices or Aboriginal Community Controlled Health Services.

Medical Home RACGP
Key elements of the medical home. Source: RACGP

Why doctors have expressed concerns

One of the key recommendations by the Primary Health Care Advisory group was to encourage patients to be engaged in their care (recommendation 3). Although the model was intended to be ‘patient-centred’, the patient somehow seems to have been lost in the discussion around the current model.

For example, it is not clear how the proposed model will encourage better coordination or comprehensiveness of care to improve the patient journey (recommendation 7).

For a long time the RACGP and other professional groups have been actively offering to work with the Government on the development of an appropriate model, but the RACGP and other GP groups were not consulted in this case. The general practice representatives on the Government’s implementation committees are not representing their professional associations and furthermore have had to sign confidentiality agreements so therefore cannot discuss ideas and recommendations with peers or policy development staff.

The Government claims that it is implementing a model based on the RACGP vision. Unfortunately the current Health Care Homes proposal by the Department of Health does not reflect the RACGP’s evidence-based, best practice model of the Medical Home, as outlined in the RACGP Vision for general practice and a sustainable healthcare system.

The RACGP has called for a rigorous trial subject to academic and scientific evaluation, rather than rushing into a phased rollout. The HCH implementation evaluation methodology is still under development. Health policy needs to be evidence-based and the evidence should to be carefully developed – otherwise it will fail patients and the Australian health system.

A correctly designed trial will properly address the challenges facing Australia, strengthen access to the delivery of high-quality care and ensure patients have a stable and ongoing relationship with a general practice.

The proposed model capitates funding for chronic disease management and treatment in general practice. It may harm patients and undermines GP-led care when funding runs out.

This major reform, which is expected to save millions of dollars in hospital care, did not receive additional funding. GP groups are concerned that the federal Government’s Health Care Homes model is inadequately funded and will not improve health outcomes for millions of Australians living with chronic and complex conditions.

An example of concerns

HCHs will be required to have a service or care coordinator for enrolled patients. As funding allocated to the HCH is in fact reallocated funding from PIP and Medicare, there is no additional money available to support this role.

There is presently not enough information available for practices to make an informed business decision about their involvement with the HCH.

Information released by the Government does not provide details on any additional support for e.g. practices in rural and remote areas and no additional funding is being provided for these areas, where there are higher costs and complexity in providing chronic health care.

The original RACGP Medical Home vision includes incentives for practices and GPs to facilitate patient-centered care, for example a complexity loading to support the delivery of patient services in areas of community need.

The RACGP vision also recommends a comprehensiveness loading: GPs and general practices that provide a comprehensive range of services can respond to the needs of the community they serve. Enhancing the comprehensiveness of services provided in the primary health sector will reduce demand for more complex and expensive services in the secondary and tertiary health sectors.

Medical Home model (RACGP)
Table: Activities and infrastructure required to achieve healthcare sustainability according to RACGP. There is a clear distinction between the Government’s HCH funding model and the RACGP Medical Home model. Source: RACGP.

The Department has indicated that payments made to a HCH are also intended to cover after-hours services where they are provided in the practice rooms. Some practices may achieve efficiencies by providing some care for enrolled patients over the phone or electronically.

Each practice will need to determine if the allocated funding in the proposed model is sufficient to provide the additional care required under the HCH model.

The Department has stated that successful HCH applicants will receive a one-off payment of $10,000. The RACGP believes that an appropriately funded HCH trial would require an average of $100,000 per practice per annum, in addition to current funding allocations for chronic disease management items and other MBS items.

As the funding of the HCH by the Federal Government is minimal, additional funding from State Governments and Private Health Funds may be necessary to make the model a success. The federal Government could assist by negotiating such payment levels as part of the HCH.

The RACGP is prepared and ready to work closely with the Federal Government on this major health reform – let’s not miss the opportunity to make Health Care Homes a success.

This article was originally posted on Croaky. Dr Edwin Kruys is vice-president of the Royal Australian College of General Practitioners (RACGP). 

The information in this article is based on public material provided by the Department of Health. Whilst all efforts have been made to ensure the details are accurate, information regarding Health Care Homes is subject to change.
Follow me on Twitter: @EdwinKruysDisclaimer and disclosure notice.

Table: Health Care Home requirements

(Source: Department of Health)

A general practice or Aboriginal Community Controlled Health Service applying to be a Health Care Home must be within one of the ten selected PHN regions and needs to:

  • be accredited and maintain accreditation, or be registered for accreditation, against the RACGP Standards for general practices;
  • participate in, or be prepared to participate in, the Practice Incentives Program (PIP) eHealth Incentive;
  • register and connect to the My Health Record system and contribute to their enrolled patients’ My Health Records;
  • participate in the stage one HCH training program;
  • use the patient identification tool to identify the eligible patient cohort in their practice or service, assess individual patient eligibility and stratify their care needs to one of three complexity tiers according to their level of risk;
  • ensure that all enrolled patients have a My Health Record;
  • contribute up to date clinically relevant information to their patients’ My Health Records;
  • develop, implement and regularly review each enrolled patient’s shared care plan;
  • provide care coordination for enrolled patients;
  • provide care for enrolled patients using a team-based approach;
  • ensure that all team members have roles that utilise their qualifications and allow them to work to their scope of practice;
  • provide enhanced access for enrolled patients through in-hours telephone support, email or video-conferencing, as well as access to after-hours care where clinically appropriate;
  • ensure that all enrolled patients are aware of what to do if they require access to after-hours care;
  • collect data for the evaluation of stage one and for internal quality improvement processes.

Lab report and cat scan

This joke was posted by a colleague. He pointed out that the scenario is very applicable to general practice. Indeed, it nicely illustrates the cost benefits of a good doctor who can often make a diagnosis without many expensive tests…

A woman brought a very limp duck into a veterinary surgeon. As she laid her pet on the table, the vet pulled out his stethoscope and listened to the bird’s chest.

After a moment or two, the vet shook his head and sadly said: “I’m sorry, your duck, Cuddles, has passed away.”

The distressed woman wailed: “Are you sure?”

“Yes, I am sure. Your duck is dead,” replied the vet.

“How can you be so sure?” she protested. “I mean you haven’t done any testing on him or anything. He might just be in a coma or something.”

The vet rolled his eyes, turned around and left the room. He returned a few minutes later with a black Labrador Retriever. As the duck’s owner looked on in amazement, the dog stood on his hind legs, put his front paws on the examination table and sniffed the duck from top to bottom.

He then looked up at the vet with sad eyes and shook his head. The vet patted the dog on the head and took it out of the room.

A few minutes later he returned with a cat. The cat jumped on the table and also delicately sniffed the bird from head to foot. The cat sat back on its haunches, shook its head, meowed softly and strolled out of the room.

The vet looked at the woman and said: “I’m sorry, but as I said, this is most definitely, 100% certifiably, a dead duck.”

The vet turned to his computer terminal, hit a few keys and produced a bill, which he handed to the woman.

The duck’s owner, still in shock, took the bill. “$150!” she cried, “$150 just to tell me my duck is dead!”

The vet shrugged. “I’m sorry. If you had just taken my word for it, the bill would have been $20, but with the Lab Report and the Cat Scan, it’s now $150.”

Big health corporates win, but who keeps your family out of hospital?

Big health corporates seem to be doing well at the expense of grassroots general practice. This raises concerns about the delivery of patient care in our communities – including keeping people out of hospital.

Last month shares in Primary and Sonic jumped around five per cent after the government promised a number of carrots, including a potential rent reduction for their pathology collection centres within GP surgeries.

Last week the government struck a deal with the Australian Diagnostic Imaging Association. The Sydney Morning Herald: “The Turnbull government forged a deal with the sector late on Friday, promising to delay the cuts for non-concession holders till next January if elected, and to evaluate commercial pressures on the sector.”

Today The Australian reported: “There are groups that are doing well from the status quo, notably the health insurers and pharmaceutical companies. Last year, Medibank Private increased its operating profit by 32.5 per cent. Not bad during a period it lost policyholders.”

“There has been a percentage decrease in spending on hospitals and general practice medical attendances in recent years. At the same time, private health care premiums continue to beat inflation.”

The Australian Newspaper: “The big winners, however, are the pharmaceutical companies. The government funds $10 billion a year (up from $7bn in today’s money a decade ago) and on top of that, consumers stump up a whopping $10bn in over-the-counter preparations. Saving even a fraction of this increment would make an enormous difference to hospitals, general practice and outpatient care.”

Meanwhile, GPs and patients are still faced with the freeze on Medicare rebates. As RACGP president Dr Frank Jones has pointed out on many occasions, this situation has placed GPs and their practices in an invidious situation whereby all patients will have to financially contribute to their consultation and practices will have to curtail some quality patient services to survive financially.

It seems to me there is something seriously wrong with the priorities in our healthcare system.

The problem with ‘record-high’ bulk billing rates

According to government data, bulk billing rates are at an all-time high: around 85% of GP services are bulk billed. This figure is often used to justify the lack of investment in general practice, including the freeze on Medicare rebates patients get back after a visit to their family doctor.

Why is this figure so high? Not surprisingly, the issue is more complex than politicians want us to believe.

According to the government it is a matter of supply and demand. In other words, they claim that GPs will not be able to introduce a fee because their patients would go to a bulk billing practice down the road.

This argument, as well as the government’s focus on record-high bulk billing figures, is misleading and doesn’t tell the whole story.

The truth about BB rates

The reality is that we don’t exactly know why bulk billing levels are high. There are several possible explanations, such as:

  • GPs have been billing compassionately to provide access to all their patients
  • GPs have been absorbing the costs of the government’s freeze on patient Medicare rebates
  • Doctors have increased their services to compensate for the low Medicare rebates
  • As a result of the ageing population more people are bulk billed.

The explanation given by the government that market forces are the reason GPs bulk bill does not do justice to the work of GPs around the country. Besides, as a result of government policies, out-of-pocket expenses for patients have been rising over the years.

Why out-of-pocket costs go up

notice
Image: As a result of the Medicare freeze on patient rebates, GP practices across Australia are getting ready to introduce fees. Source: Twitter

GPs are genuinely concerned about their patients first and foremost and, no matter what politicians say, GPs have been bulk billing a large proportion of their services because they know that many patients would not seek medical care if they had to pay a fee of $15-$20 per visit.

Unfortunately the government has indicated it will not further index Medicare patient rebates, and as result of the government’s long-term Medicare freeze, practices across Australia will be forced to introduce fees.

This was the whole idea behind the government’s original co-payment plan and the reason the Medicare freeze has been dubbed a ‘co-payment by stealth‘.

The short-term ‘savings’ created by the Medicare freeze will likely result in more health problems due to delayed GP visits, and drive up costs in the longer term. A typical case of a penny wise and pound foolish approach.

Downward spiral

What if practices don’t introduce a fee? A bare-bone, high-turnover model is one way bulk billing practices can sustain themselves: doctors may decide to see 7-8 patients per hour instead of 4-5. The question is of course: how safe is this and how long can they keep doing this?

High bulk billing rates, yes – but is this the health care system we want for Australia?

Out-of-pocket costs comparison
The focus on high bulk billing rates is misleading as it only tells part of the story. At the same time Australians pay more out-of-pocket for medical care than many other countries, which creates barriers to visiting a family doctor. Source: RACGP

The bulk billing statistics tell us what percentage of services is bulk billed, not patients. We also know that Australians already pay more out-of-pocket for their care than many other countries, which creates barriers to visiting a family doctor. These figures are rising, so clearly the bulk billing statistics only tell part of the story.

Instead of looking at bulk billing rates as a measure of success, we should be carefully monitoring the out-of-pocket health expenses in Australia.

GP Leaders have warned that we’re facing a downward spiral – which is a risk for the nation’s health and leads to higher overall costs. Even if the freeze on Medicare patient rebates is reversed – which is an absolute must – we’re not out of the woods.

We need well-resourced, sustainable primary care funding models that support high quality care for our patients and are easy to implement at grassroots level.

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.

The baby, the bathwater and a better health system

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.

Outcome payments and performance…

“G’day doc. I’m a little embarrassed to bring this up but…”

“No worries, you know you can be honest here. Let’s check your blood pressure first. It was a bit high last time.”

“Oh… ok. Not dangerously high I hope?”

“Well it was just above the benchmark, which is concerning. As you know I don’t get paid if I don’t look after your pressure. Let’s see… 140 over 90. Uh oh. I’m afraid we have to bump up your medications.”

“But doc, could it be stress? I wanted to tell you that…”

“Stress, stress… That’s all well and good but Medicare doesn’t care what the cause is. If it’s too high I miss out. And if I miss out you miss out, you know that don’t you? We also have to talk about your weight target. As I’ve told you before, if you don’t lose those extra pounds our practice cannot afford to look after you any longer.”

“Are you listening to me? John and I broke up last night. I’m a mess!”

“I’m sorry to say that there’s no incentive payment for counselling anymore. Please do me a favour and book in for your pap smear on the way out. Last time you were late and we missed the deadline for our quarterly Medicare bonuses. We don’t want that to happen again do we?”

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

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.

Don’t go to your doctor, the minister wants you to see the pharmacist instead

Pharmacies will be handed $1.26 billion for delivering healthcare services. Good for them. But meanwhile the government is not prepared to increase the Medicare rebates patients receive when they see a doctor.

As a result of the new health policies, visits to the doctor will become more expensive in the years to come, whereas pharmacies will be paid more to deal with health problems. With this move Health Minister Susan Ley seems to make a clear statement: Don’t go to your doctor, see the pharmacist instead.

A vague agreement

It could be me but I’m not entirely sure what the Health Minister will sign off on – it’s all still a bit vague:

The Pharmacy Guild says on its website: “The Government has committed to $50 million over the Agreement for a Pharmacy Trial Program to trial new and expanded community pharmacy programs which seek to improve clinical outcomes for consumers and extend the role of pharmacists in the delivery of healthcare services through community pharmacy.”

National President of the Pharmaceutical Society of Australia Grant Kardachi says: “PSA particularly welcomes the doubling in this agreement to $1.26 billion of funding for the provision of patient-focussed professional services.”

According to Australian Doctor magazine, “some $600 million will be spent on ‘new and expanded’ services, but there is no detail on what services this will cover.”

One thing is certain: Pharmacies are going to deliver more healthcare services – and at the same time the freeze on indexation of the Medicare rebates comes at a cost for patients.

Questions

Here re my questions:

  • Is Minister Ley’s decision helping to improve teamwork within primary care, or is it creating more confusion and frustration for patients and their doctors?
  • Can pharmacists and their assistants offer the same quality healthcare as doctors and practice nurses?
  • Can the person who is selling the drugs give independent health advice?
  • Why not spend part of the money on increasing the rebate patients get back from Medicare after visiting their doctor?
  • Why not spend part of the money on improving access to practice nurses and GPs?
  • Does this mean that doctors will miss opportunities to pick up on health problems, because patients will see the pharmacy assistant instead?
  • When the Pharmacy Guild talks about ‘evidence-based’ services, what do they mean? (given the fact that many community pharmacies also sell unproven remedies and products).

What do you think, is this good policy or not?

Why the ‘You’ve been targeted’ campaign against the co-payment was so successful

“We don’t have to engage in grand, heroic actions to participate in the process of change. Small acts, when multiplied by millions of people, can transform the world.” ~ Howard Zinn

Not many people know that the main message of one of the most successful campaigns of the Royal Australian College of General Practitioners (RACGP) against government policy was largely inspired by one patient.

At the height of all the commotion about the co-payments, patient advocate Ms Jen Morris posted a message on Twitter suggesting a different response to the government proposals: Instead of focusing the campaign on doctors, she said, we should be focusing on the consequences of the policy for patients.

We’re sorry

I used her simple but powerful message in a leaflet (see image). It said:

We’re sorry to hear your rebate will be slashed. (…) It’s not that we haven’t tried, but the Government doesn’t seem to listen to GPs. They may listen to you.”

We are sorry
The original design inspired by Ms Jen Morris.

Not long after I posted it on my blog and social media channels, the RACGP President contacted me. He wanted to include the message in a national campaign. I thought it was great that the RACGP was using social media and that they took notice of what was being said. Not long after, the You’ve been targeted campaign was unleashed by the college. The message was similar to the original, inspired by Jen Morris:

“Your rebate from Medicare will be CUT (…). We have been vocal with Government but it’s falling on deaf ears. They haven’t listened to us but they will listen to you.”

The RACGP had listened to patients and many of their members who wanted a patient-focused campaign. The You’ve been targeted approach showed that every GP surgery in Australia can be turned into a grassroots campaign office if necessary. After other groups, including the Consumers Health Forum and the AMA, increased pressure on the government, the co-payment plan was dropped.

I spoke to Ms Jen Morris and RACGP President Dr Frank Jones about the role of patient input, the use of social media and what we can learn from the remarkable campaign – as there is still a lot of work to do (for example to reverse the freeze on indexation of Medicare rebates)

A pay cut for wealthy doctors?

Morris: “I opposed the co-payment, but was concerned that the original approach adopted by doctors’ organisations misjudged the public’s values, as well as public perceptions of doctors’ wealth and social position. In the initial stages of the campaign against the proposed co-payment, doctors’ organisations, and thus media coverage, were framing it as a pay cut for doctors.”

“Misframing the situation like this made it harder for those of us opposing the changes to explain the various proposals, including Medicare rebate freezes, in a way which the public could understand. It also made it easier for the public to write the problem off as not their concern, but rather a pseudo ‘workplace relations’ issue between doctors and Medicare.”

“At the time, the public were reeling from a budget widely touted as disproportionately impacting the most vulnerable and disadvantaged people. In a social context of widespread public perception that doctors of all stripes are wealthy. So there was little public sympathy when the doctors’ lobby cried foul because the government was trying to ‘cut their pay’. There was a sense that as well-off professionals, GPs should take their fair share of the fiscal blows and ‘cop it on the chin’.”

“The government played perfectly into the combination of these two problems. By later touting the co-payment as ‘optional’, they painted GPs who chose to charge it as opting to squeeze patients rather than take a pay cut.”

‘Extremely poor policy’

Jones: “The RACGP repeatedly raised its concerns with government over many months regarding the impact of a co-payment on the general practice profession and its patients. As GPs we have an obligation to speak up and oppose any policy that will impact on our patient’s access to quality healthcare. We know that poor health policy drastically affects the ability of GPs to deliver quality patient healthcare, and this was extremely poor health policy.”

“When it became apparent the RACGP’s concerns were not gaining the traction required to influence change, we decided it was time to increase pressure. While advocacy has always been a major component of the RACGP’s work, it has recently taken a more public, contemporary approach to these efforts.”

“In the case of You’ve been targeted, this meant ensuring patients were also included in the conversation and encouraged to stand united with GPs to protect primary healthcare in Australia. We collectively see hundreds of thousands of patients a day and knew that a campaign bringing GPs and patients together would present a strong united voice.”

You've been targeted
The succesful RACGP You’ve been targeted campaign

The strength of the campaign

Morris: “Like most public policy debates, successful campaigning against the co-payment was contingent on securing public support in a political PR contest, which means getting the public on side. I believed that re-framing the issue around patient interests was the key to changing public perceptions, and winning the PR battle.”

Jones: “The RACGP took notice of what patients were saying about the co-payment and listened to our members who were telling us they wanted a campaign that focused on how their patients would be impacted. This is what led to the creation of You’ve been targeted.”

“The response to the RACGP’s change.org online petition was a big step for the campaign, with more than 44,800 signatures obtained in less than one week. While the campaign gained momentum through protest posters, use of the social media hashtag and sending letters to MPs and this allowed for concerns to be heard, the online petition was a collective demonstration of the sheer extent of those concerns.”

“A campaign’s strength is intrinsically connected to how powerfully it resonates with its audience and You’ve been targeted hit all the right buttons in this respect campaigning on an issue that affected every single Australian, young and old.”

Novel approaches

Morris: “If doctors and patients can capitalise on common ground and present a united front from the outset, the weight of political force will rest with us.”

Jones: “In terms of closer collaboration on advocacy campaigns, the RACGP feels there will be significant opportunity to work with health consumer organisations, given the mutual priorities of better supporting patient care.”

“The RACGP has already partnered with consumer organisations including the Consumers Health Forum (CHF) with whom it produced a number of joint statements. Most recently, the RACGP and CHF partnered in a joint submission regarding the deregulation of pharmacy locations and ownership.”

“The RACGP has consumer representatives on its key committees and boards. We have a history of working with consumer groups on important issues, and will continue to do so moving forward.”

“In light of the RACGP’s recent campaign successes, we will increasingly use social media as a platform to act as a voice for Australian GPs and their patients. Social media is new age media and the RACGP is committed to keeping pace with technological advances to ensure its members are effectively represented.”

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

It’s time to cut the red tape

It had taken a year to organise the required paperwork to make the move from the Netherlands, and finally I was here, about to start my job in a remote hospital.

However, the manager on the other side of the desk had other ideas. She looked at me over her glasses and shook her head. I wasn’t allowed to work, she said, because my Medicare provider number would take another month to come through.

Of course, this was just the beginning. After a few years working in the bush, I was thrilled to qualify for a permanent Australian residence visa. But first I had to pass the international English language test — again.

“G’day mate, do you really need me to come to the big smoke?” I asked a clerk at some department over the phone. “I’m flat out looking after this mob in the back of Bourke. I passed that exam ages ago, before I came to the Lucky Country. Surely me Strine hasn’t got worse since I’ve been here. Crikey, the rellies back home reckon I have a dinky-di Aussie accent.”

Needless to say, I had to sit the English test again.

Red tape bugbears

This was a decade ago, but things haven’t got any better. The GPs Down Under (GPDU) Facebook group, a new, quickly growing online community of Australian GPs and registrars, listed their ‘red tape bugbears‘ earlier this month.

The amount of time and energy GPs waste filling out forms and jumping through bureaucratic hoops is gobsmacking.

One GP recently posted on the GPDU Facebook page: “For practices employing a new rural doctor, there are at least 14 different forms across Commonwealth and State jurisdictions. Some have to be completed online, some need to be scanned, some mailed — yes, with a stamp. And some faxed.”

Hospital bureaucracy is also a big bugbear for many GPs. For example, in Queensland the public hospitals have an extensive referral ‘criteria’ for each department. GP referrals that don’t tick their boxes – often checked by non-medical staff – are simply refused.

One orthopaedic outpatient department doesn’t accept a referral until GPs have faxed a completed three-page ‘hip and knee questionnaire’.

Other health professionals can also add to the GPs’ burden when they selectively take over parts of our job under the notion of helping to reduce our workload.

But it doesn’t always work out that way as one GP on the GPDU site recently highlighted when she told of how her local pharmacy happily manages her patients’ warfarin doses, but only as long as the INR is within a safe range.

“Apparently this service is more ‘convenient’ as well as lucrative for the pharmacist. Until the INR level is more than 2.5. Then, late Friday afternoon, the pharmacy demands I manage the warfarin dose. So then it’s suddenly my problem,” she posted.

Knee-jerk reaction

Red tape is often a knee-jerk reaction to a problem and not usually the best solution.

An estimated 25,000 patient consultations are lost every month while doctors are waiting for PBS Authority call centre operators to answer the phone. Meanwhile, our Medicare-funded sick certificate ceremony is estimated to cost the Australian economy $3 billion a year.

It’s time we did something about it.

Collaboration with other professions and organisations is more important than ever. If we help hospitals solve some of their outpatient department problems, our workflow will improve too. GPs need to negotiate innovative solutions that are mutually beneficial and acceptable. Building relationships, communicating and networking are the key to success.

We are in an ideal position to show leadership. This means we have to organise ourselves better, learn to be good followers, and support those who are trying to build bridges, including our peak organisations. No doubt we will occasionally have to compromise and, in some instances, lift our game.

I realise this is not easy in the current climate of cuts and freezes, but if we fail to do this, others will continue to take control of primary care. I love Australian general practice – it’s a great profession and the reason why I came to Australia. But we must protect what’s good and make it future-proof.

My call to action to colleagues, the colleges and the AMA is simple: please help and make things easier.

This article was originally published in Australian Doctor Magazine.

How safe is the patient safety net?

In the ‘Blogging on Demand’ series you get to choose the topic. If you have a great idea you want the world to know about, feel free to contact me. Perth GP Dr Jacquie Garton-Smith proposes a change to the PBS safety net to protect vulnerable patients.

“One thing that my patients with chronic disease on lower incomes find difficult,” says Dr Garton-Smith, “is that they have to pay for all their medications until they hit the safety net. Even if people are only paying the lower rate for scripts, it adds up if they are on a number of medications. I have seen it affect compliance at the beginning of the year when they have to decide which medications they need most.”

The general patient safety net threshold is currently $1,453.90, and the concessional threshold $366. When someone or their family’s total co-payments reach this amount, they only have to pay the concessional co-payment amount of $6.10 until the end of the calendar year. Concessional card holders get standard PBS scripts for free after they reach the threshold.

The PBS co-payment and safety net amounts, effective from 1 January 2015:

General patient co-payment: $37.70

Concessional co-payment: $6.10

General safety net threshold: $1,453.90

Concessional safety net threshold: $366.00.

A safer solution

Garton-Smith: “Loading the costs into a few months of the year and then being free the rest of the year for concessional card holders is concerning. My patients tell me the safety net is supposed to help them but doesn’t – until it kicks in. For someone who has diabetes, hypertension, hypercholesterolaemia, arthritis, reflux, depression and sometimes osteoporosis, asthma or COPD, you can see the impact. This is not an unusual scenario.”

“It would be so much easier if the cost could be spread out over the year for people likely to hit the safety net. It would also prevent people attempting to stock-pile at the end of the year. I realise most people don’t get more than 5 scripts a month but those who need to are often managing serious health problems.”

Medication adherence 

Research has shown that when co-payments for medications increase, more people stop their treatment. This includes essential preventive medications, and as a result more visits to the doctor and hospital may be required.

Associate professor Michael Ortiz said in Australian Prescriber: “Some have argued that greater cost sharing does not undermine overall patient health because patients facing rising costs will reduce their consumption of perceived non-essential medications more than their consumption of essential drugs. However, ‘preventive’ drugs are different, because not all patients understand the long-term benefits of taking medicines for conditions such as hypertension and hypercholesterolaemia.”

“Some of my patients need to delay filling scripts they see as less essential

Garton-Smith: “A patient I have seen needs to buy more than ten medications every month at a cost of $85. Sometimes there are extra costs, for example if he needs antibiotics. On a single disability pension he gets $840.20 per fortnight, so approximately 5% of his income is spent on scripts until he reaches the safety net threshold, generally by May. Even though he gets a lot of prescriptions filled just before the end of December, he usually needs to delay filling scripts that he sees as less essential at the start of the year.”

Professor Michael Ortiz in Australian Prescriber: “The current approach to PBS savings is that the Government takes most of the cost savings, but increases co-payments and safety net thresholds each year in line with inflation. Increasing co-payments reduces medication adherence and ultimately may compromise the care of some patients.”

Thanks to Dr Jacquie Garton-Smith for the topic suggestion.

Why doctors run late: 12 red tape challenges

In the ‘Blogging on Demand’ series you get to choose the topic. If you have a great idea you want the world to know about, feel free to contact me. Last week members of the GPs Down Under (GPDU) Facebook group posted their red tape bugbears. Melbourne GP Dr Karen Price, who is an admin of the group, suggested to blog about the issues that slow doctors down.

Patients are often understandably frustrated about waiting times. A couple of years ago I blogged about the reasons why I run late, including the daily healthcare bureaucracy doctors have to deal with. I’m sad to say the amount of red tape hasn’t changed.

Australia is not making good use of its medical workforce. Example: An estimated 25,000 patient consultations are lost every month while doctors are making phone calls to the PBS authority script phone line.

Instead of reducing the amount of paperwork for doctors – so they can see their patients quicker – other professionals are asked to take over parts of the clinical job.

There are of course other reasons why doctors run late, but the focus of this post is on healthcare bureaucracy. So here is a summary of the GPDU Facebook discussion on the abundant red tape that slows doctors down, summarised in 12 points.

#1: Sick notes

Medical certificates for all sorts of issues seem to be increasingly popular, and every day thousands of doctors issue tens of thousands of notes.

This is not only a significant cost to Medicare, it also increases waiting times. Doctors have no problem issuing a genuine sick certificate as part of a consultation, but often people come in when they are getting better, just to get a certificate at the request of their employer.

Sometimes medical certificates seem to be used to shift liability when doctors are asked to declare that someone is fit for certain (recreational) activities. And, do we really always need a medical certificate when our children cannot attend daycare or school?

#2: Provider numbers

Medicare provider numbers are a bugbear for doctors and registrars, and have been for years.

One GP said: “Repeated applications for provider numbers through Medicare with the same information are such a waste of time. Surely they have my name, address, e-mail and multiple provider numbers already. An online portal with a ‘click’ application or submission of paperwork for would be amazing.”

Another GP: “For practices employing a new rural doctor there are at least 14 different forms across Commonwealth and State/Territory jurisdictions – some forms online, some scannable, some mailed, yes, with a stamp, some faxed. Software that would streamline at least some of those forms – even going to different destinations but auto-filled – would encourage practices to take more registrars and more prevocational doctors.”

#3: PBS authority phone line

Another major bugbear: Australian doctors have to ring this phone line before they can prescribe common medications. They must ring every time a script runs out, even if the patient has been taking the medicines for many years. The line is often busy and doctors and their patients are kept waiting. A short consultation can easily become a more expensive long consultation as a result of the waiting time.

Removing some medications from this scheme to a streamlined electronic procedure has not changed prescribing habits, which seems to indicate that the phone line doesn’t really serve a purpose. Also, some countries without a script line have lower antibiotic resistance patterns than Australia.

The approval process is bizarre. Doctors are asked the daily dose for an adrenaline emergency auto injector or have to spell the name of the drug as call centre operators have no clue.

Why doctors run late

A GP said: “After 5 minutes of waiting I’ve run out of small talk with the patient. By 6 minutes I’m almost considering to talk my patient out of starting Champix. And by nearly seven minutes waiting my usually cheerful manner with the call centre operator is gone.”

Another GP: “Sitting on the phone waiting for authority – why do I need permission from a bureaucrat to prescribe something?”

#4: Medicare and Centrelink

Medicare and Centrelink take up a lot of valuable time. The MBS criteria for example have been a constant source of confusion and stress for doctors. The endless paperwork is a challenge for doctors and practice managers.

One GP said: “Centrelink manages to outsource a tremendous amount of form filling in. Surely it contributes to green house gasses…”

Another GP: “Medicare forms… Some you can scan and e-mail back, some must be posted, others can be faxed but not emailed.”

#5: Handwriting charts, notes and scripts

Nearly all GP practices are computerised. Still we get requests from organisations to handwrite important documents.

Residential aged care facilities and community nursing teams often require handwritten medication orders, and don’t accept a printed chart generated by GP desktop software.

Some nursing homes and most hospitals ask that doctors, including visiting GPs, handwrite their notes. This also includes shared antenatal care. One GP said: “While I agree that the handheld obstetric records are exceptionally important, doubling up and having to write in them plus your computerised notes is inefficient – or print out your notes and have multiple loose prices of paper floating around each time.”

“I have some intellectually disabled adult patients in a group home and the script situation is tedious,” a doctor said. “Every panadol, every small change to prescribing, has to be documented and faxed to the chemist, and every consultation requires a form to be filled out and the consultation notes to be printed.”

The law requires doctors to handwrite opiate scripts underneath the printed text – and on both copies of the script – to reduce the risk of forgery. This has become obsolete for many practices as an electronic copy of the script can be sent to the pharmacy to avoid fraud. Other innovative developments such as real-time prescription monitoring will further make handwriting scripts unnecessary.

#6: Working with kids, working with elderly, working with vulnerable elderly checks

These new requirements for AHPRA registered doctors seem unnecessary. “I have to get not one single police check, but three checks,” said a GP. “‘Working with kids’, ‘Working with elderly’ and ‘Working with vulnerable adults’ checks before can work in country hospital, all at my expense. I work in an already highly regulated industry, I am trusted with scalpels and mind-altering drugs, and have an annual AHPRA registration renewal, but must do all this foolishness every few years.”

#7: Proof of AHPRA-registration

Doctors often have to provide a copy of their AHPRA registration, but registration details including the expiry date can be easily looked up by anyone on the APHRA website

#8: Travel cost assistance 

A GP said: “Filling out Patient Assisted Travel Scheme forms for rural patients is getting more tedious: We now have to write a letter stating exactly why our patients need an escort. Ticking the box isn’t enough.”

#9: Pharmacies

Pharmacies can add value in many ways, but when it comes to collaboration there is room for improvement.

One GP said that a pharmacy happily managed her patient’s blood thinners, but when the INR results were outside the normal range they referred back to the GP. “Apparently this service is more ‘convenient’ as well as lucrative for the pharmacist. Until the INR level is more than 2.5…Then, late Friday afternoon, the pharmacy demands I manage the warfarin dose. So then it’s suddenly my problem. They get paid lots of money for a service I do for free.”

A common bugbear of GPs is the ‘owing scripts to pharmacy’ problem. Some pharmacies provide ongoing medications even if the script has run out. As a result patients miss their check-ups with the doctor and request an ‘owing’ script from their GP at a later stage.

In defence of the pharmacy: doctors are not always on time with sending scripts to the pharmacy.

#10: Accreditation

One GP expressed concerns about the never-ending accreditation requirements: “Not the principle, but the realities. Broadly speaking: Individual clinicians need to be accredited multiple times, not just by AHPRA, but by government (working with children checks etc), local hospitals, regional training providers (to be supervisors) etc.”

“Practices need multiple accreditations – separate ones to be training practices for example – and all very painful. Regional training organisations need to go through hoop jumping accreditation processes by the colleges, the colleges by the Australian Medical Council. Never-ending and so much time wasted.”

#11: Care plans, EPCs and mental health care plans

The rules designed by Medicare to manage chronic care in general practice have been the topic of heated debates. For example: Patients with a chronic illness cannot claim their Medicare rebate when the GP does a care plan and treats an acute problem on the same day. This means that many patients have to come back on another day, further increasing waiting times.

“Care plans and mental health plans interrupt my patient contact and workflow,” one GP said. “If a GP was rewarded more this templated rubbish would be done anyway as part of usual care by the good doctors.”

Another doctor said: “Did you know that people used to actually pay to see allied health professionals prior to GP care plans? Now it seems all allied health contact is required to be limited to five free visits per year.”

#12: Hospital bureaucracy

Making an appointment for a patient can be challenging sometimes. One GP said: “The hospital ‘outpatients direct’ won’t let me help organise an appointment for a patient without them being with me at the time, because of confidentiality. But I wrote the referral and need to know the date of the appointment to arrange transport or they won’t get there.”

Many hospitals have referral criteria and they’re not aways flexible: “Queensland public hospitals have extensive referral criteria. They don’t accept GP referrals that don’t tick their boxes – often checked by non-medical staff.”

Hospitals can really slow GPs down with extra paperwork requirements: “The orthopaedic outpatient department doesn’t accept a GP referral until we have provided them with a completed 3-page ‘hip & knee questionnaire’.”

Sometimes hospital doctors send a patient back to the GP for a referral to another hospital doctor. Many GPs feel that in some (especially urgent) cases an internal referral with a copy to the GP would be much more efficient.

Rural GPs often work in hospitals and emergency wards. Transferring sick patients to a bigger hospital is a challenge in some states: “Western Australia has a long way to go: I first have to call the RFDS, then the hospital and speak to the accepting team – if lucky one call, if unlucky several calls. Then I need to call the ED to inform them about the expected patient. I have to call the RFDS for an update. Then the registrar calls back after speaking to their boss. Then the hospital bed manager calls and lets me know there are no beds available, so I need to go to another tertiary hospital etc. I hardly have time to look after the patient and talk to their next of kin.”

One GP said about requesting investigations: “To organise a CT-scan at the hospital from a rural ED, I have to make phone calls to the radiologist, the CT tech, the ED consultant, the specialty registrar (if applicable), and the bed manager. If one of those phone calls is missed… hoo boy, you’d think that I’d killed Santa Claus.”

We need ongoing conversations with each other, managers and decision makers to avoid unnecessary red tape and improve the patient journey across various parts of the health system.

Thanks to Dr Karen Price for the topic suggestion.

UK doctors in Australia – Why they won’t be going home any time soon

The numbers are telling: About 1,500 UK doctors move to Australia and New Zealand each year. This exodus is causing havoc in England. A GP-shortage creates high workloads and overstretched doctors, and a survey showed that over half of UK GPs plan to retire before the age of sixty. This stressful situation has prompted a coming home campaign to entice doctors to go back to the United Kingdom.

Why are doctors leaving, and, will they move back to save the NHS?

Dr Nathalie Departe is a UK-trained GP working in Fremantle, Western Australia. “I moved to Australia in 2009 for a change of scenery. I had visited Australia before and loved it, so when my husband found himself in a career hiatus, we thought we would enjoy the sunshine for a few years.”

“Working in Australia was a breath of fresh air. Patients were pleased to see me, understanding if I ran late, and I was rewarded and not penalised if I spent time with a complex patient to sort out their management. Access to pathology and radiology services was prompt, rather than a standard 6-8 week wait for an ultrasound, and access to allied health services didn’t compare – good luck trying to see a clinical psychologist on the NHS.”

“Initially it was a bit odd to bill patients and not provide free care at the point of need, but I soon came to value the transparency of the transaction. The integration between private and public care makes private care accessible and affordable in Australia, rather than in the UK where private care has to be funded in full.”

Escaping the NHS

“In Australia I can arrange imaging quickly, receive the results the next day and organise appropriate and timely care

Dr Janaka Pieris moved to Brisbane in 2010 to ‘escape’ the NHS: “When I think back to my working life as a GP in South East London, I have two overriding memories: there was never enough time in the day to do the work asked of me, and there was no means of limiting my workload. NHS General Practice is a sink for everything no-one else will take responsibility for. Many GPs feel unable to decline these demands – many of which are not NHS work and therefore unfunded – and as a result, are drowning in work.”

“When a patient presents with painless obstructive jaundice in the UK, I have no option but to refer in to hospital, because I have no access to appropriate imaging, or I cannot get it done in a timely fashion. In Australia I can arrange the imaging quickly, receive the results the next day, discuss the case with a specialist and organise appropriate and timely care. It is much more satisfying from a professional perspective.”

Dr Tim Leeuwenburg made the move in 1999, immediately after his internship in the UK. He is now a GP at Kangaroo Island in South Australia. “I was married to an Aussie and always knew I’d be coming to Australia for love and a better lifestyle.”

“That was 15 years ago. Since then I’ve vicariously witnessed the demise of UK medicine – and am anxious that Australia doesn’t make the same mistakes: Other professions trying to do doctors’ work, capitation and performance payments, privatisation, walk-in clinics, phone advice lines, revalidation. They are all seemingly good ideas, but not evidence-based and all have served to emasculate the profession and increase the number of doctors seeking to retire, locum or emigrate from the cesspit that is the NHS. None of these measures have reduced costs or increased quality.”

“The myth of the ‘fat cat’ wealthy GP laughingly enjoying his round of golf whilst poor patients helplessly waited for his attentions was regularly portrayed in the media

Departe: “Despite working in a nice area and enjoying my job, I had a growing sense of unease with the way UK general practice was going. There seemed to be ever changing targets to qualify for practice payments with increased red tape and less time for consultations.”

“There was a general loss of respect for the role of a GP; it was not unusual for patients to demand medication, tests and home visits inappropriately, then to be outraged if you questioned the need for it. The myth of the ‘fat cat’ wealthy GP laughingly enjoying his round of golf whilst poor patients helplessly waited for his attentions was regularly portrayed in the media, and I felt that general practice was being devalued in the eyes of public and politicians alike.”

Dr Mark McCartney left the UK in 2013 because he was not happy with the working conditions in the NHS, but moved back to England after 12 months because of family circumstances. “There is a huge cultural difference in Australia, where there is a mixed health economy of private and state-subsidised services. The NHS is free at the point of access for patients, and service always struggles to meet the demand and prioritise appropriately. UK hospitals are dysfunctional places and the effects of this trickle into General Practice.”

“UK GPs are mostly paid on the basis of capitation payments depending on the number of patients registered, with additional payments for reaching clinical targets and a small amount of fee for service payments. There is now a shortage of GPs and we work in an environment of running faster and harder just to meet demands, without additional incentives or resources.”

“Australian GPs have the luxury of earning a high proportion of income from fee-for-service payments, including patient fees and Medicare payments. The more patients they see and the more services they provide, the more they earn. Clinical practice is also more interesting with rapid access to x-rays and scans. It is a professionally motivating environment to work in.”

Would you move back to the UK?

Dr Pieris is sceptical about the fully funded induction and returner scheme: “Firstly, it is manifestly insulting to suggest that doctors who have worked in similar systems, such as Australia, need retraining to work in UK general practice. I do more medicine in Australia than ever I did in the UK.”

“Secondly, if people are leaving because of a failed system, a sensible approach would be address those failings, not try to tempt people back into the same environment they left.”

“To return would require most GPs to undertake 6-12 months of supervised training, and to surrender to ridiculous bureaucratic imposts

Departe: “Why would I return to a role where I am restricted in my clinical practice by financial constraints, strangled by paperwork, stressed out by time pressures, undervalued by patients and politicians and where I would earn less money for more work and more stress?”

“To return would require most GPs to undertake 6-12 months of supervised training, and to surrender to ridiculous bureaucratic imposts,” says Leeuwenburg. “The reason doctors are leaving the NHS is because of unfettered demand from patient ‘wants’ not ‘needs’, and reduced income as a result of capitation. Why on earth would you go back?”

McCartney: “Very few GPs will return, unless they have personal or family reasons. UK GPs are retiring early, but this does not seem to be the case in Australia. There are also huge barriers to doctors wishing to move back to the UK in terms of medical registration and licensing to practice. The NHS is wasting resources trying to recruit in Australia and they look foolish because of that.”

Doctor’s advice

“My message for governments,” says Departe, “would be Stop undervaluing good general practice! Good general practice has been proven to provide better value for money and a more integrated care approach than secondary care. By all means, regulate general practice to maintain appropriate standards of care but then pay us accordingly and let us get on with being general practitioners.”

Leeuwenburg: “Listen to grassroots doctors, not NHS managers who have destroyed the NHS and are now sprucing their wares in Australia. Nor to academics who think things like capitation and revalidation are necessary. Our Australian system is marvelous and we should be proud. Sure, there is fat in the health system that could be trimmed, mostly in hospitals and specialists, but primary care is overall incredibly efficient and GPs do a great job.”

“The UK government needs to stop attacking GPs and listen to doctors and the BMA, who have been largely ignored for the last ten years

“Ofcourse there are some outliers, but there are many more who are hard working and ethical, doing the right thing for patients and Medicare. Alienate GPs and risk the collapse of a great primary care system. It will cost more if we surrender to the failed experiments of the UK or privatise us with private health funds.”

“The UK government needs to stop attacking GPs and listen to doctors and the BMA, who have been largely ignored for the last ten years,” says McCartney. “Doctors want to work in an effective service so that they can focus on caring for patients. Learn from Australia that good access to radiology for GPs can keep people away from hospital until they really need to be there.”

Pieris: “The UK Government should let us do our jobs. Trust us. Stop interfering. No-one is saying regulation and scrutiny are not required. However, GPs are not some malign enemy. Stop treating us as if we are.”

Recommended further reading: Doctors from overseas, about my experiences as as a Dutch doctors starting Australia.

Image source: www.queensland.com

The looming war between pharmacists and doctors

The looming war between pharmacists and doctors
Image: Pixabay.com
The war (…) was an unnecessary condition of affairs, and might have been avoided if forbearance and wisdom had been practised on both sides ~ Robert E. Lee

Separating the medication prescribers from the dispensers has merit. One of the advantages is that doctors and pharmacists don’t get tempted to diagnose problems to sell more drugs.

The Australian Pharmacy Guild wants to change this. They prefer pharmacists to do health checks, give advice and perform interventions such as vaccinations – while at the same time selling the solution to the problems they identify.

The Guild’s strategy is marketed as providing better access to patient care, and is apparently based on overwhelming international evidence. Indeed, in some countries pharmacists offer a wider range of services.

I’m not sure it’s always better overseas. One New Zealand doctor seemed very unhappy about pharmacists managing medical problems (and I have heard similar stories from other countries):

“I practise in New Zealand where pharmacists are allowed to treat ‘easy’ diagnoses like urinary tract infection [UTI]. Last week I consulted with a young lady who had had two diagnoses of UTI and two courses of trimethoprim [an antibiotic]. When I examined her she had a significant UTI, thrush and the possibility of a chlamydia infection, results awaited. Nothing is ‘easy’ in medicine!

The Pharmacy Guild may be a politically clever bunch, but they should have suggested a multidisciplinary solution here. Their strategy will create a backlash. In the end nobody will be better off.

Where to from here?

The signs are on the wall. Dispensing medications is not sustainable for pharmacies. Just like video rental shops had to change their business model because people started downloading movies and using automated DVD rental kiosks, this particular part of the pharmacist’s job may soon be history. The authors of an article in the British Pharmaceutical Journal ‘Dispensing: it’s time to let it go’ said: “If the aspirations of pharmacy fulfilling a clinical role integral to public healthcare is ever to be realised, community pharmacists must shift their focus away from dispensing and towards NHS service provision.”

The key here is integration. According to the authors medications could be provided in-house by health care organisations or delivered by mail, and the focus of pharmacists should be on providing integrated services like medication reviews and drug utilisation reviews. This would indeed employ the skills of pharmacists and at the same time ad value to patient care provided by other health professionals.

Or maybe pharmacists should be made responsible for quality control of over-the-counter medicines and help to stamp out misleading claims made by the domestic complementary medicines industry.

We need honest medication advice. “(…) It comes as a shock to walk into some pharmacies to see them urging products on customers where there is no evidence base of effectiveness,” said NHMRC boss Professor Warwick Anderson recently. “If you’re providing advice and care to patients, you should be clear about the evidence for the treatment.”

The pharmacy industry is comfortably protected by their community pharmacy agreement with the Federal Government, and state laws stipulate only pharmacists can own a pharmacy. A new pharmacy cannot set up shop close to an existing pharmacy. Other professions, like doctors and lawyers, don’t have this competition protection.

The service expansion drift of pharmacy-owners will eventually provoke a response from the AMA and RACGP and other medical organisations. The idea of the pharmacist in general practice has been floating around for a while. Doctors may demand dispensing rights and lobby for an end to the pharmacy cartel.

A study in the Medical Journal of Australia showed that dispensing doctors issued fewer PBS scripts than non-dispensing doctors. This is one argument for dispensaries in GP surgeries; other arguments are evidence-based medication advice and consumer convenience. Think about it: What’s easier than, after having seen the doctor, walking to the dispensing machine in the hallway, scanning your script and receiving your medications? Robotic dispensing reduces medication errors (see video below) and nobody is suggesting multivitamins, supplements or probiotics at the same time.

But just because a service is more convenient, doesn’t mean that it is a good solution. Doctors should not do the pharmacist’s job, just like pharmacists would do well to stay away from medical services.

There is still time

Pharmacy-owners face reduced profits because the Government has set lower prices for generic medications under the price disclosure arrangements. Although it is understandable they are looking for other income streams, this is a dead-end. The last thing we need is a war between pharmacists and doctors.

Needless to say it’s not in the interest of health consumers. It will create confusion, duplication, false reassurance, frustration, missed screening opportunities, fragmentation of care and higher costs.

Doctors have to accept change too. If people feel they cannot access a GP when they need to, we should improve this. One solution would be to fund nurse-lead walk-in vaccination services within the safe, clinical environment of the GP surgery. The pharmacist can play a role as part of the multidisciplinary team.

The current community pharmacy agreement expires in June 2015. There is still time.

Follow me on Twitter: @EdwinKruys

Health is defence – Universal care vs ‘user pays’

Guest post

Gold Coast GP Dr Andrew Rees submitted this thought-provoking guest post about universal health care vs a ‘user pays’ system.

For some decades now, we Australians have been living in a country where basic health services have been provided with heavy government subsidies or in many cases have been provided at no direct cost to patients.

Now the Australian Liberal government wants to change the system so that it is more predominantly ‘user pays’. Despite ample evidence that such a system is more expensive and inefficient than our present approach, and that the care delivered is no better, there is a desire to adopt what has been demonstrated to work poorly elsewhere in the vain hope that it will work well here.

I understand that there are those who believe that universal health care or anything approximating it is a ‘Socialist’ idea. Preventing disease and treating the sick and injured might, however, be regarded as a way of protecting the community from harm. Indeed, we have other institutions established by the government to protect our community. The civil authorities include the fire, ambulance and police services. The Army, Navy and Air Force provide military defence. Customs and Border Protection also play a role.

So, some might say, “Why do I have to pay for the Air Force? If I had a constitutional right to bear arms (we don’t), then I could just buy my own jet fighter and go and shoot up any bad guys. Socialists have forced this on us, surely. Bunch of Commies making us pay for armed forces. Police, too. Nobody ever broke into my house. Why should I have to pay taxes so the police can investigate your burglary? You got burgled – you pay for it!”

The reason that we, as a society, tend not to think this way (although I am sure that there are some who do) is that there is recognition that some services are best provided on a universally available and publicly funded basis.

In fact, Section 51 of the Australian Constitution provides Federal Parliament certain powers including ‘to make laws for the peace, order, and good government of the Commonwealth with respect to (for example) “… the naval and military defence of the Commonwealth …” and a little later on “… pharmaceutical, sickness and hospital benefits, medical and dental services” …’

It seems to me, therefore, that those who framed the Australian Constitution recognised that providing ready access to health services was a way of protecting the nation as a whole. Sick people are less productive than the well. Infectious diseases spread easily without treatment and where appropriate, vaccines and quarantine. That individuals owe a debt of care to other members of a society is not a new thought:

“No man is an island, entire of itself; every man is a piece of the continent, a part of the main. If a clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as if a manor of thy friend’s or of thine own were: any man’s death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bells tolls; it tolls for thee. (John Donne)

The Australian Government has a Constitutional obligation to protect the Commonwealth. Attacking and weakening the health system whether delivered in the doctor’s office or in a State run (ultimately Federally funded) hospital suggests a lack of resolve on the part of Government to discharge this duty. A person who mounted such a spirited attack against his or her own defence force in a time of war would probably be regarded to have committed treason.

However, because the enemies those health professionals protect the community from are more insidious – such as smoking, heart disease, cancer, and infectious diseases – there is a perception that this kind of attack on the health system and its practitioners is somehow acceptable.

If we accept that in ill-health we share a common foe, then as Thomas Hobbes’ states:

“Whatsoever therefore is consequent to a time of war, where every man is enemy to every man, the same consequent to the time wherein men live without other security than what their own strength and their own invention shall furnish them withal. In such condition there is no place for industry, because the fruit thereof is uncertain: and consequently no culture of the earth; no navigation, nor use of the commodities that may be imported by sea; no commodious building; no instruments of moving and removing such things as require much force; no knowledge of the face of the earth; no account of time; no arts; no letters; no society; and which is worst of all, continual fear, and danger of violent death; and the life of man, solitary, poor, nasty, brutish, and short. (Hobbes, Leviathan)

No doubt, the Liberal Government would reason that they are not attacking or endangering the system, but rather they are going to make it better. However, they have no evidence that their approach is likely to have any success. Rather, evidence from the US is that using a ‘user pays,’ predominantly commercial health fund system leads to burgeoning expenses and substantially decreased access for the majority of the community.

Under the US health system, Health Management Organisations (HMOs) may perversely interfere with the ability of appropriately trained physicians and surgeons to provide the most appropriate care because of a commercial requirement to maximise financial returns for the HMO.

Bacterium or bullet, cancer or cannon shell, tuberculosis or terror attack – the community is still worse off because of the suffering of the individual. Whether one dies from influenza or an improvised explosive device, one is still dead. Leaving citizens to fend for themselves and fund their own care will certainly reduce the number of attendances in the short term.

However, the real cost of a change to a predominantly ‘user pays’ system will be far greater. What kind of life is it that we seek for the members of our community? Neighbourly, prosperous, pleasant, lovely and long: or solitary, poor, nasty, brutish, and short?

Dr Andrew Rees

Disclaimer and disclosure notice.

6 key conditions for private health insurance in in general practice

Private health insurers are gearing up to enter the general practice market. But it appears their plan is a copy of the dreaded US-style ‘managed care’ approach.

It’s best to keep health funds at arm’s length or else they will decide what care can, and can’t be given – instead of the patient and the healthcare provider. Therefore, I suggest that six conditions must be met before private health insurers can engage with general practice:

#1: Universal access

Every Australian should have equal access to a GP, independent of insurance status.

#2: Freedom of choice

People should have the option to choose their GP and private specialists; this cannot be dictated by health funds. Patients together with their doctors are best at deciding which tests and treatments are appropriate, not third parties like insurance companies.

Patients should always be given the option to choose and change health funds and insurance products.

#3: Transparency 

Health funds must provide a straightforward package covering GP and/or basic private hospital care – as well as more comprehensive packages. Exclusions should be kept to a minimum. Health funds should make patients aware of exclusions and any other limitations before they buy a product.

To assist consumers choosing the best health insurance that suits their circumstances, an independent Government website should monitor, compare and publicise all available insurance packages.

#4: Professional autonomy

GPs and practice staff need support to be able to provide good care; this also means they should not be overloaded with red-tape, reporting requirements and KPIs. For the same reason health funds should not cause delays in treatment. GPs have the right to set fees to ensure practice viability.

#5: Evidence-based care

Only proven, appropriate, and cost-effective care should be covered.

#6: Stakeholder involvement

Health consumer organisations and the medical profession need to be engaged, as this will likely lead to better outcomes. New regulation should be put in place to safeguard compliance by all parties.