Has Australian general practice moved one step closer to the British NHS?

In 2019, the Department of Health, via its practice incentive scheme, will not only start setting the key performance indicators of general practice but also further tighten its grip on practice data. It is not unlikely that the Department’s strategy will create the same issues the National Health Service is currently encountering: loss of patient-centeredness of care, unreasonable KPIs and low doctor morale.

The redesign of the Practice Incentive Program (PIP) has been in the cards for a while. The introduction of a new quality improvement (QI) payment system was deferred for 12 months in May 2018 because of concerns that it was not fit for purpose.

Central role of PHNs

If it goes ahead in May 2019, the impact of the new scheme will be significant. The big change will likely be that Primary Health Networks (PHNs) become exclusive “QI providers” for general practice. This means that they will extract, analyse and store practice data and present GPs with benchmark reports. Many PHNs have already started collecting data in anticipation of the changes.

To be eligible for quality improvement incentive payments, practices will have to demonstrate to PHNs that their performance is on par with the Department’s KPIs. Although analysis and benchmarking of clinical data are becoming increasingly important to improve patient care, there are many issues with the proposed PIP overhaul.

Initially, there was talk about more organisations becoming QI providers, such as the Royal Australian College of General Practitioners (RACGP) and the Improvement Foundation, but, according to Medical Observer, it looks like there will be no profession-led alternative to the PHN model and, as a result, practices will not be given a choice of QI providers.

General practice is at risk of gradually losing control over its quality improvement processes, which will no doubt leave many grassroots GPs dismayed.

Professional buy-in?

The main issue with the scheme is related to professional buy-in. The Department of Health has gone through the usual process of consulting the profession, but it has always been clear that the PIP redesign was going to occur regardless of the opinion of GP groups.

The Department may claim in its communications that the KPIs are supported by the various professional bodies, but the level of engagement, trust and satisfaction with the new QI system will be low for various reasons.

First, this is an example of a top-down government solution, largely designed by the Department of Health. As we have seen with the My Health Record and Health Care Homes, this approach usually creates just as many problems as it is trying to fix.

Similarly, there has been a lack of engagement with the e-health PIP (ePIP) scheme, which requires practices to upload shared health summaries to the My Health Record to remain eligible for incentive payments or ePIP. This may have given the Department a countable number of uploads, but there is no evidence to suggest that it has improved meaningful use of the My Health Record or quality of care in general practice.

Weak evidence

In the PIP redesign process, only payments to practices have survived. For example, the aged care incentive payment to GPs providing care to patients in residential aged care facilities will be scrapped. This incentive is worth $3000–$5000 per doctor. Many have argued that it is incomprehensible that funding benefitting aged care is removed at a time when residential aged care facilities need more support to provide the medical care required.

By stopping these service payments to individual doctors, the incentives will be one step further removed from those who are responsible for the actual quality improvement activities. Again, this does not inspire confidence in the Department’s new QI system.

Measuring performance against KPIs in combination with performance payments will almost certainly create new problems. Quality indicators used by governments around the world are often easy to measure isolated parameters that have limited valuefor complex systems such as general practice.

The evidence to support financial incentives is weak, and the British Quality and Outcomes Framework (QOF) pay-for-performance system has illustrated what can go wrong: QOF has not improved care but did result in the loss of the patient-centredness of care and has created a significant decrease in doctor morale.

No funding priority

The new QI PIP will be subsidised by a shift of funding from other PIP and SIP incentives — which has been labeled as “robbing Peter to pay Paul” by the Australian Medical Association. In 2016, $21 million were removed from the PIP budget to partially fund the Health Care Home trials. The last budget announcements made it clear that there will be no increase in PIP funding in the near future. The PIP scheme, introduced in the 1990s, has never been indexed.

The Department of Health has not yet provided clarity on what the PIP scheme will look like beyond May 2019. This lack of transparency about long term planning creates uncertainty for practices. Although the expectations will start off low, it is to be expected that the Department will adjust the KPIs upwards over time, wanting more for less.

One of the PIP eligibility criteria for practices is accreditation against the RACGP’s Standards for general practices, and it will be interesting to see if upcoming changes to the PIP scheme will affect the percentage of practices that take the effort to go through the accreditation process.

Data extraction

Finally, general practice is not only facing loss of control of quality improvement but is also about to miss out on an opportunity to become custodians of its clinical data. Although the QI PIP data will be extracted from GP practices, it will likely be managed and controlled by PHNs and other government agencies, such as the Australian Institute of Health and Welfare.

When the government defunded the Bettering the Evaluation and Care of Health (BEACH) study in 2016, general practice lost its most important longitudinal source of data. It doesn’t take much imagination to figure out what will happen with the QI PIP data when, in a future reform cycle, PHNs or other government agencies involved are subject to funding cuts or cease to exist altogether.

The Department of Health’s underlying thinking seems to be that the responsibility for quality and data should be taken away from the profession, even though the government’s own data governance practices don’t always inspire confidence.

Professional response

The department should have given professional organisations the responsibility to execute a mutually agreed strategy, acceptable to all parties, including custodianship of data for quality improvement purposes.

Our peak bodies are working hard behind the scenes to negotiate the best possible outcome. It is more important than ever for the profession to work through any differences and present a united front. The question remains, can we stem the tide of increasing departmental control or has general practice definitely moved one step closer to the NHS?

This article was originally published in MJA Insight.

You can’t have your cake and eat it too

The Practice Incentive Program is shrinking but the government expects new quality improvement systems and general practice data.

Most GPs were underwhelmed, to say the least, when they heard about the changes (read: cuts) to the Practice Incentive Program (PIP). Cutting the funding for nursing home visits is a hard sell for the Department of Health and the Federal Health Minister.

This is the wrong message at a time when there are more elderly people with complex chronic health problems in need of appropriate medical care, preferably in the community.

I have heard about various ‘fixes’, including improvements to the Medicare Benefits Schedule (MBS) schedule (good idea) and introducing nurse practitioners (not necessarily a good idea) – but nothing has been confirmed and it all sounds a bit like policy on the run, not a planned and coordinated strategy.

Quality improvement

The scrapped incentives, including the aged care service incentive payment (SIP), will be used to set up a quality incentive payment system (QI–PIP) in GP practices. There are certainly arguments for supporting an enhanced quality improvement system in general practice, but was it the right decision to sacrifice the aged care payments?

We need practice data to review and improve patient care. I agree with the RACGP position that the development of a QI–PIP should assist general practices to undertake quality improvement activities.

However, the RACGP has also indicated that it will not support measuring performance against key performance indicators (KPIs) or so-called ‘quality indicators’ in combination with performance payments. There is just not enough evidence that this will significantly improve care in the long-run, but there is evidence of harm, including detrimental effects on the doctor–patient relationship and practitioner burnout.

Although we have had verbal assurance from the Department of Health that the new QI–PIP – to be introduced in May next year – will not be a pay-for-performance system, the longer-term plans are unclear. This has raised many concerns and it will hinder business planning for general practices.

Data deal

In return for the quality improvement payments, practices will be required to hand over their patient data to Primary Health Networks (PHNs) under the current proposal. From there, the data will flow to other agencies but – just like the My Health Record data – we have not yet heard for what purposes it will be used, and what the implications will be for individual GPs within practices. Many GPs have indicated that they are not prepared to hand over data to their PHN or the Government.

Another big issue is the eHealth Practice Incentive Payment (ePIP), which was originally introduced to strengthen practice IT systems, but is now used to make practices – often practice nurses – upload shared health summaries to the My Health Record. As we are moving to a My Health Record opt-out system later this year, the time may have come to review the ePIP and make it more meaningful for general practice.

Lastly, the practice incentive funding was introduced in the 1990s and has never been indexed. In 2016, $21 million was earmarked for removal and used to partially fund the Health Care Home trials.

It all sounds like another example of the Government wanting more for less. You can’t have your cake and eat it, too.

This article was originally published on newsGP.

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.

A great quality tool for health bloggers, podcasters and patients

A while back I came across a new tool for those who, like me, use Dr Google but are concerned about the quality of some of the available online health information.

The tool contains two checklists and has been designed for medical education resource producers, editors, end-users, and researchers. I’ll let the authors explain:

“Through a rigorous research process, a list of 151 quality indicators for blogs and podcasts was formed and subsequently refined to elicit the most important quality indicators. These indicators are presented as Quality Checklists to assist with quality appraisal of medical blogs and podcasts.”

The checklists have three domains: credibility, content and design, and cover topics such as avoiding bias and conflict of interest, providing clear information about the identity and qualifications of the author, and referring to sources. The checklists also focus on design and didactic value.

I believe they can be useful for patients to assess the quality of online health resources. For more information read about the 6 warning signs that will help you stay clear from quackery sites.

This tool has the potential to take many health blogs and podcasts to the next level. It is available at no cost and can be found here.

Quality checklist
A quality checklist for blogs. A separate checklist is available for podcasts. Source here.

Source: Colmers IN, Paterson QS, Lin M, Thoma B, Chan T. The Quality Checklists for Health Professions Blogs and Podcasts. The Winnower 2:e144720.08769 (2015).

UK-style revalidation in Australia would be a big mistake

Australian doctors are kept on a short leash. I recently renewed my registration with the Australian Health Practitioner Regulation Agency (AHPRA). This annual ritual is always interesting.

Like thousands of other doctors, I first had to fill out an online questionnaire. As usual, AHPRA wanted to know if I had a physical or mental impairment, disability, condition or disorder – including substance abuse or dependence – that would detrimentally affect my capacity to work as a doctor. I was reminded that I’m required by law to declare any impairments.

There were questions about criminal records, compliance with the law, continuous professional development, indemnity insurance, work history and immigration status. I was advised that if I did not give the required information, I could lose my registration.

Finally I dutifully transferred the required $724 into AHPRA’s bank account.

High professional standards

The yearly AHPRA registration procedure symbolises the way doctors are controlled in Australia. Contrary to common belief, doctors allowed little freedom.

Before doctors can prescribe certain medications, they have to call Medicare to get approval. Prescribing habits are monitored. Doctors are audited randomly to make sure billing practices are not out of line with peers. They may be prosecuted if there is a deviation from the average. In most states, doctors have to report colleagues who are not performing optimally.

At the same time, professional medical standards in Australia are high. Take the accreditation standards of the Royal Australian College of General Practitioners, or the CPD requirements. Both quality assurance programs have become more robust over the years and are continuously being reviewed and improved by the College.

QI&CPD programs recognise ongoing education to improve the quality of everyday clinical practice by promoting the development and maintenance of medical skills and lifelong learning.

Is there a problem?

Why is there still talk about revalidation of doctors? Is the public concerned about the quality of Australian doctors?

The national AMA patient survey indicated that GPs are considered by the public to be trustworthy, knowledgeable and experienced. A large patient satisfaction survey endorsed by the RACGP found there was a very high level of satisfaction with General Practice in Australia.

Another study published in the MJA also showed that patients reported high levels of satisfaction with GP care, and for many years Australian doctors have been in the top three most trusted professions in the annual Roy Morgan research.

Based on numbers from Canada, AHPRA estimates that 1.5 per cent of Australian medical practitioners are performing ‘unsatisfactorily’. I’m not sure Canadian figures can be applied to Australia, but 1.5 per cent of unsatisfactory performers in any group is low. It appears that any potential problem lies with a significantly small minority of doctors.

Carpet-bombing the profession

There are many revalidation models – from strengthening CPD to targeting those at high risk of complaints, to the full- bore version rolled out in the UK. But if the AHPRA tries to identify substandard doctors, carpet-bombing the whole profession is problematic.

Dr Steve Wilson, Chair of the AMA (WA) Council of General Practice, questioned in Medicus magazine whether revalidation would address those who failed to practise to agreed levels. And if it did, he asked, would that be a sign of impairment or does it reflect personal style, or lack of time, training, experience or adequate remuneration?

Competency checks of doctors may sound appealing to the public. I’m sure some politicians will love the rhetoric. But simply copying the UK’s revalidation system would be a mistake.

About 5,000 doctors a year are considering leaving the UK, and many come to Australia. Bureaucracy is one reason they emigrate. The last thing we need in Australia is more regulation, red tape and stressed-out doctors.

Existing quality systems

In recent years, our healthcare system has seen several unsuccessful concepts not supported by evidence. Think for example about the super clinics program and  some of the accompanying cost blowouts, delays and disappointing results.

It will be easier and cheaper to build on existing quality assurance systems.

This article has previously been published in Medicus, the AMA(WA) magazine.

Disruption in healthcare is happening (whether we like it or not)

Healthcare, and particularly medicine, are slow-moving beasts. This doesn’t mean that innovation isn’t happening. In fact, it’s happening at an alarming speed and doctors are grappling with a quickly expanding knowledge base.

But the highly regulated, traditional industry is vulnerable to external disruption, and we’re seeing more and more examples:

  • DIY tests like skin cancer apps and pap smears
  • Online script services
  • Skin checks at the pharmacy
  • Vaccination services outside medical practices
  • Medical tourism

The flip side of convenience

Disruption is not necessarily the same as innovation. Disruptive services or products are simpler and more convenient to use, but their quality is often poorer.

In healthcare, the risk of disruption is that it affects health outcomes. It may lead to fragmentation and loss of opportunistic screening. I’ll give two examples:

Example 1:  More providers does not equal better care

A busy family doesn’t have the time to visit the doctor and decides to use convenient online health services. As a result they hardly ever visit their family doctor, and if they do, their doctor does not have the complete picture as more health providers are involved in the care.

Example 2: Convenience does not equal safety

Women doing their own pap smears at home may take incorrect samples. Although avoiding the ‘stirrups’ in the doctor’s office is a big plus, the risk of avoiding an expert examination is that things get missed.

The way forward

Disruption in healthcare is happening, whether we like it or not. “Successful entrepreneurs naturally look at opportunities in terms of the jobs they can do for customers,” say the authors of this article. Although it is unlikely that the doctor can be replaced by technology, certain aspects of the healthcare process can.

I believe there are 3 ways the healthcare industry should respond to external disruption:

  1. Continue to listen to health consumers
  2. Develop our own disruption processes
  3. Communicate the strengths and qualities of our services

Marcus Tan, GP and CEO of HealthEngine said in Australian Doctor magazine: “GPs are ideally suited to lead this cultural shift. GPs are highly skilled in managing risk and uncertainty, and are well equipped to make the leaps required to innovate.”

Indeed, if we don’t do it ourselves, others will.