During my medical training in Amsterdam I witnessed many of the effects of the Dutch liberal policies such as the legalised practice of euthanasia and their model on cannabis. The Netherlands was also the first country in the world to legalise same-sex marriage over 15 years ago.
When it comes to same-sex marriage I support this. Not so much because of health reasons but simply because I believe it is fair.
I acknowledge that LGBTIQ communities (Lesbian, Gay, Bisexual, Transgender, Intersex and Questioning) have had a lot to endure. I also respect that there will be people who disagree with me here and may have other opinions.
In Australia we now have the odd situation of the voluntary Australian Marriage Law Postal Vote, where we are asked to vote on the question: Should the law be changed to allow same-sex couples to marry?
The RACGP position
The postal vote has created healthy debate but also vigorous campaigns by the ‘yes’ and ‘no’ camps. Organisations and businesses are being asked by their members and customers to take side and the health sector is no exception.
Unfortunately there have been inappropriate and hurtful comments on social media and elsewhere. It seems to me that these unintended consequences of the postal vote are doing more harm than good.
The Royal Australian College of General Practitioners (RACGP) has a diverse membership of more than 35,000 GPs with a range of views. The RACGP Council believes that members should make their own, personal decision about marriage equality.
This position does not imply that the RACGP is against same-sex marriage, or for, and it does not mean that the College or general practitioners do not acknowledge the many challenges facing the LGBTIQ community.
It also does not mean that the RACGP president is personally neutral on this topic – I know that he supports same-sex marriage.
To better understand the position of the RACGP Council it is good to look at the history and the role of the College. For many years the organisation has mainly focused on training, education and quality standards. In recent years the RACGP has moved into advocacy to improve support of and recognition for the provision of quality general practice care.
The RACGP has invested heavily in a large database of guidelines, standards, policies and position statements driving general practice care. However, there has not been a demand from members to advocate on public policy issues such as climate change, sugar tax, alcohol sale, refugees or marriage equality – as a result the College has not developed a position on many of these topics.
The RACGP recently sent out a poll asking members if they would like the RACGP to advocate on a wider range of public policy issues, and one of the examples given was marriage equality. The response: One hundred members participated and one third stated that they did not think this was a role for the College.
This is only a very small sample and clearly more debate is required. The direction of the College will ultimately depend on what the membership wants. Traditionally the Australian Medical Association (AMA) has been doing this kind of advocacy very well, but perhaps there is a role for the Colleges?
An important argument for change is that it would increase the College’s social responsibility. As family doctors we come in contact with all of life’s challenges so we may as well participate in the various debates.
On the other hand, it will be difficult for the College to be everything to everyone. It may create more disputes.
Lastly, various RACGP sources including the Standards for General Practices affirm and underline respectful and culturally appropriate patient care and, in accordance with the law, strongly condemn discriminatory treatment of people based on their personal characteristics.
I’d urge everyone to be kind and considerate and show respect for others in this important debate.
Addendum 02/10/2017: RACGP Council has issued a statement in support of marriage equality.
At the time of writing Edwin Kruys was vice-president of the Royal Australian College of General Practitioners (RACGP).
The report is based on various sources, including research commissioned by the Royal Australian College of General Practitioners (RACGP) and the MABEL (Medicine in Australia: Balancing Employment and Life) Survey.
Some of the key messages from the report:
Mental health is today’s biggest health problem and will continue to be an issue in the future
The GP is the most accessible health professional and should be utilised to keep Australia well
Patient out-of-pocket expenses in general practice are increasing and present a barrier to patients accessing the required care
The bad news
GPs report that psychological issues such as depression, mood disorders and anxiety are the most common health issues they manage. Mental health was flagged by RACGP members as the health issue causing most concern for the future, followed by the often related problems of obesity and diabetes.
GPs believe that mental health and obesity are two key health policy issues the Federal Government should prioritise for action.
From the benchmark report: “This is a clear warning of both the current frequency and future potential impact of psychological ailments on individuals, the community and the broader health sector. It is also a stark reminder that the personal and financial health costs associated with obesity and diabetes are expected to escalate.”
However, the number one health policy issue flagged by GPs is the problem of the low patient Medicare rebates. GPs have indicated this requires immediate Federal Government action to make sure that access to high quality healthcare is maintained.
As the cost of providing high-quality health services and running general practices continues to rise, GPs are finding it more difficult to bulk bill patients. Between 2013-14 and 2016-17 the growth of the bilk billing rate has slowed down.
Patient out-of-pocket contributions continue to increase each year as Medicare rebates fall further behind the real cost of providing general practice services.
The good news
Most Australians can see their GP when they need to. Nearly all patients (99.3%) report that they are able to see a GP when they need to and most people are able to get an appointment for urgent medical care within four hours.
Australians access GPs more than any other part of the health system. They report that they visit their GP more than they receive prescriptions, have pathology or imaging tests, and see non-GP specialists.
Eighty-three per cent of patients report that they visit their GP multiple times a year, including 11% who report seeing their GP 12 times or more. The availability of GP services has further increased with extended opening hours.
GPs coordinate care within multidisciplinary teams and Australians report positive experiences with their GP.
More time with patients
The RACGP is arguing for Medicare changes that will incentivise doctors to spend more time with patients – by increasing the patient rebate for longer consultations.
RACGP President Dr Bastian Seidel said: “We believe when GPs are spending more time with their patients, that leads to less prescribing, less pathology, less referrals, enhanced continuity of care, and that would, of course, mean less hospital presentations as well.”
General practice accounts for less than 9% of total government recurrent expenditure. The RACGP, AMA and other groups believe this is inappropriate as more health benefits for Australians can be gained by investing in primary care.
The success of Facebook is based on sharing content with friends and family. I’m a fan of social media but in healthcare sharing of information is often a no-go zone.
Doctors don’t like sharing patient information with third parties for various reasons: they have sworn an oath, must adhere to a code of conduct and have an ethical and legal obligation to safeguard the privacy of their patients.
The patient-doctor relationship is built on trust: patients need to feel safe to share their concerns with a doctor. Unfortunately in Australia there are a few worrying cracks in the system, such as the access of insurance companies to health records.
Life insurance industry
Last week I had the opportunity to present the concerns of the Royal Australian College of General Practitioners (RACGP) at the Inquiry into the Life Insurance Industry of the Joint Parliamentary Committee on Corporations and Financial Services in Canberra.
This is an example of inappropriate sharing of information with a third party (which differs from sharing between health professionals) and can have serious ramifications.
5 reasons not to share
There are five reasons why third parties such as insurance companies should never have access to health records:
People often don’t understand that ticking a box on the life insurance application form means that insurers can have access to their health records, including confidential information that has been shared with doctors, often over many years, and may not be relevant to the insurance company.
In the experience of GPs many people withdraw their consent once they are aware of the possible repercussions, and in some cases discuss with their GP to submit a targeted, more relevant medical report instead.
The therapeutic trust relationship between a GP and a patient could be affected.
Patient knowledge of the issues they may face after disclosing symptoms or seeking treatment, particularly for mental health issues, is likely to discourage disclosure and help-seeking, which adversely affects patient wellbeing.
Understanding that medical records can be requested by an insurer may lead GPs to under-document or under-identify patients at risk in efforts to make sure the patient’s access to insurance is not affected.
GPs have advised that they feel they are placed in a difficult situation where they need to ensure adequate documentation of their consultation with patients while also considering the broader impact this may have on their patient. This in turn may have medicolegal ramifications for doctors.
Insurers not only have access to but also store thousands and thousands of health records. This raises all sorts of questions with regards to data usage and standards around security, privacy and confidentiality.
Many GPs are concerned about the risks of misinterpretation by insurers when reviewing a patient’s consultation notes.
Medical consultation notes are a comprehensive written record of concerns, symptoms, examinations, investigations, treatments and planned reviews. They function as an aide memoir and are not made for the assessment of risk for insurance purposes.
There should be a tightening of the requirements around requests for full medical records by insurers. With patient consent, doctors should only be asked to provide a targeted and relevant report to the insurer.
There is also a clear need for greater patient education on consent and the release of health information to insurance companies.
It’s a sobering fact: apparently more people die from drug overdose than road traffic crashes.
Perhaps even more concerning is that most of these overdose deaths in Australia are not caused by illicit drugs, but by the fatal mixture of two or more pharmaceuticals – often medications I and my colleagues prescribe to help people improve the quality of their lives.
Take-home message one: The combination of opioids (like oxycontin) and medications such as benzodiazepines (e.g. valium) can be fatal – even more so if mixed with alcohol.
Dealing with drug dependence
Abuse of prescription drugs is a big problem and doctors and pharmacists are often unaware that some of their patients collect prescriptions from several prescribers and pharmacies. This can go unnoticed because our computer systems are not yet linked and the reporting systems have flaws.
For several years the RACGP, AMA and other health bodies have called for the introduction of Australia-wide Electronic Reporting and Recording of Controlled Drugs (ERRCD). Coroners have also been advocating fiercely for an ERRCD system.
Prescribers and dispensers should be able to access and share prescription information but this has only been happening in real-time in Tasmania.
Since 2009 doctors and pharmacists in Tasmania can access prescription information if there is a legitimate clinical need, via a secured, encrypted website. The information includes what opioid medications have been dispensed and when, and if there are concerns about drug dependence or ‘drug seeking’ behaviour.
The Tasmanian real-time prescription monitoring system has stopped doctor-shopping for restricted drugs. Similar data comes from overseas: New York has seen in a 75% drop in patients seeing multiple prescribers after the introduction of ERRCD.
Some sources claim the Tasmanian system has reduced opioid-related deaths, although it has been argued we need a better way of analysing prescription drug deaths.
ERRCD is an essential tool to help prescribers and dispensers, but is only one part of the solution to reduce opioid prescription misuse. We also need to review how we look after at-risk patients, including those living with mental health problems or substance use disorder.
Road to recovery
Chances are that I may actually not improve the quality of my patients’ lives by prescribing opioids or benzodiazepines long-term. There are drawbacks: side effects, risk of dependence, serious bodily harm and death. Occasionally the drugs can make the pain worse, a phenomenon called opioid-induced hyperalgesia.
Take-home message two: There is limited evidence of the long-term efficacy of opioids for the management of chronic non-cancer pain.
Some have argued that opiates such as Endone (oxycodone) have become the new paracetamol and that we also need to reappraise the treatment of pain in the acute setting.
GP teams, allied health practitioners and pharmacists will play a crucial role to help tackle the issues around drugs of addiction – while supporting their patients at the same time. Sometimes input will be required from addiction, mental health or pain disciplines.
Many resources, tools and education opportunities are available to assist doctors. Meanwhile, state governments need to get on with the much-needed introduction of real-time prescription monitoring programs that will ultimately connect into a national network.
A majority of members of the Royal Australian College of General Practitioners (RACGP) voted against the proposed modernisation of their 16-year old governance structure.
As the saying goes, in the end we only regret the chances we didn’t take – I sincerely hope this will not be one of them.
At yesterday’s RACGP member meeting 45.87 percent voted for, and 54.13 percent voted against the resolution. As a result the College will continue with its 13-member representative Council model.
The modernisation proposal was the result of a member-initiated governance review process that started 3 years ago. The proposed model would have introduced skills-based board positions and a representative council that would have better reflected the membership.
The two GP-led governance structures were set up to hold each other accountable. The model was designed to create a greater diversity of voices and thinking within the College.
But it wasn’t to be. Some of the arguments against the proposal were that the board of 7 members was too small, would contain non-GPs, and that the Board-Council model was wrong.
In the end RACGP members have decided and that needs to be respected. It looks like College records have been broken with regards to voter turnout which is always a good thing – and possibly the result of the technology which allowed members to participate in the online member meeting and vote from their digital devices anywhere in Australia.
I thought it was great to see so many GPs participating in the various discussions about governance and I’d like to thank everyone for their input.
The current model has served us well. It has allowed the RACGP to grow successfully over the past years – even though it has its flaws. At some stage the College engine will need replacement, but for now we’ll continue to drive with the old one. Time for reflection.
As the Royal Australian College of General Practitioners (RACGP) has been growing rapidly to 34,000 members, one of the big issues the College grapples with is the perceived ‘disconnect’ between the College and its members. A new proposed governance model aims to better connect the membership with College leaders.
Every organisation needs to review itself once in a while. The RACGP last did this 16 years ago so it’s about time for an organisational update. The proposal includes a GP-led, partly skills-based Board and a larger representative Council. The two structures would be set up to hold each other accountable.
One of the reasons behind the proposed governance model is that the old structure is somewhat conflicted. The problem all Councillors have had up to now is that they represent a group or state within the College on the one hand, and are directors on the other.
This can lead to Councillors having to take a position such as this: “The group I am representing wants A but, putting my directors hat on, I think we should do B in the interest of the organisation” (excuse the simple example to illustrate the point).
In other words: Council, at present, may be faced with situations where it is not able to represent the membership well because directors’ duties, by law, take priority. We can’t be good directors and good representatives at the same time – but are probably managing ok overall. However, this is one of the reasons why there is a perceived structural ‘disconnect’ in the organisation.
The proposed new governance model splits these two functions (representation vs directorship) between a Council and a Board which will hold each other accountable. This is an essential, but much overlooked, purpose of the new model.
It will improve the representative function of Councillors by freeing them up to work purely on behalf of our members, while Board members (directors) will mainly look after the business side of the RACGP. This model is not new and is used in other colleges and not-for-profit organisations to manage this very issue.
I believe the proposed model breathes new life into the RACGP and general practice by creating a Council that will better reflect its membership. The model creates places for New Fellows as well as Registrars and will foster new leaders with a greater diversity of voices and thinking.
Should the Royal Australian College of General Practitioners (RACGP) be lead by GPs only or a more diverse mix of directors? In the lead up to the College’s general meeting on May 30 board diversity has been one of the topics of debate.
The composition of boards and councils of other Colleges has been used as an example but, more important than what has been happening so far, is where we will be in 5, 10 or 20 years time. A new Governance Model should prepare the RACGP for future challenges. This requires more than just looking at what other Colleges do today.
The Trump response
When President Donald Trump ordered a closure of the US borders to prevent Muslim refugees and visitors entering the country, the Scientific American republished How Diversity Makes Us Smarter by Katherine Phillips, Professor of Leadership and Ethics and senior vice dean at Columbia Business School.
“Simply being exposed to diversity can change the way you think”
Professor Phillips argues that diverse teams are more innovative than homogenous teams, referring to a body of research by organisational scientists, psychologists, sociologists, economists and demographers.
“Diversity enhances creativity”, she says. “It encourages the search for novel information and perspectives, leading to better decision-making and problem solving. Diversity can improve the bottom line of companies and lead to unfettered discoveries and breakthrough innovations. Even simply being exposed to diversity can change the way you think.”
Vernetta Walker of BoardSource, an organisation based in Washington supporting nonprofit board leadership, says that achieving diversity on a nonprofit board is a challenging but doable and essential task.
“Don’t assume everyone agrees about what diversity and inclusion mean for the board,” she says. “Before asking ‘How do we become more diverse?’ boards must ask ‘Why do we need to become diverse?’
“Boards with a good gender balance perform better”
The evidence to answer that question is coming largely from the field of gender diversity. Louise Pocock, Deputy Executive Director of the Australian Governance Leadership Centre says that several studies have shown that boards with a good gender balance perform better.
Although board diversity often refers to gender, momentum is growing that diversity is also about other aspects such as ethnic and cultural background, age, education, skills, experience and boardroom behaviours and attitudes.
“A board comprised of diverse individuals brings a variety of life experiences, capabilities and strengths to the boardroom,” she says. “There is greater diversity of thought and a broader range of insights, perspectives and views in relation to issues affecting the organisation.”
“Diversity of thought may, in turn, encourage more open-mindedness in the boardroom, help generate cognitive conflict and facilitate problem solving, and also foster greater creativity and innovation. It also reduces the risk of ‘group think’ – where board members’ efforts to achieve consensus overrides their ability to identify and realistically appraise alternative ideas or options in relation to the organisation.”
Reluctance to adapt
Sally Freeman and Peter Nash from KPMG Australia state that boards of tomorrow need to be nimble, and responsive to the rapidly changing environment.
The authors say that, in order to create board diversity it is important for boards to recognise their conscious and unconscious biases. “The key to good diversity is getting the mix right to achieve a shared purpose – overcoming biases and assumptions – and then, how that mix is managed, which requires a chair who is adept at facilitating open and robust discussion. Boards don’t make a huge number of key decisions but the ones they do make need to consider the breadth of challenges and opportunities faced by the business.”
“Sometimes boards are reluctant to adapt”
“However, sometimes boards are reluctant to adapt. These are the boards that struggle to see how current social, environmental, geo-political or technological issues could impact their business – at times only recognising the consequences once it’s too late. There is further evolution required for those boards who take the view that these issues are ‘not real’ or do not impact their organisation. Diversity can assist with surviving this evolution.”
Suzanne Ardagh from the Australian Institute of Company Directors (AICD) says that board diversity is a component of a strong performing board and that research now shows that high performing boards are very much aware of how their board composition could contribute or detract from robust discussions, decision-making and ultimately, performance.
She says that a mindset shift is required to create more diversity on boards and that this is essential to set up an organisation for the future and for long-term success. “I would urge Chairs and Directors to make that change which society is seeking. Boards need to become more inclusive of the wide and diverse community that we are – it is an imperative that becomes more acute every day.”
“A mindset shift is required to create more diversity on boards”
Vanetta Walker advises boards to expand diversity, but limit board size. “Many organisations identify their needs for inclusiveness and diversity only to confront the biggest challenge of all: how to fill all those needs without weighing down the board with too many members. When a board is too large, some members may feel disengaged, and decision-making can become cumbersome.”
“Diversity really impacts decision-making, and good decision-making is good governance,” says CH2M Hill board member Georgia Nelson (see video). “Having diverse folks around the table really drives you to let go of conventional thinking. You get out of traditional boundaries and you begin to think about things in a different way, and by doing that innovation grows and prospers.”
When trying to inform government policy, the medical profession is often up against lobbyists representing large corporate commercial interests. This usually does not improve patient care. It is also difficult for patients to distinguish between groups that advocate for the public good versus those that are after increased profits, power or influence. Below are some examples.
There are strong indications that funding for after-hours medical services in the community is used inappropriately. For example, I have received reports from some of these services (who mostly employ non-GPs) delivering repeat prescriptions after-hours to patients’ homes. After-hours visits classified as “urgent” attract a Medicare rebate of $130–$150 compared to non-urgent visits of $55 and $36 for standard GP surgery consultations.
The after-hours industry is booming.
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 last financial year. This trend is seen at a national scale and there is no reasonable explanation for the steep rise in home visits.
What we need is ethical and efficient after-hours deputising services that work seamlessly with day-time medical services.
Although several after-hours services recently quit the lobbying group – including the Canberra After-Hours Locum Medical Service, the Melbourne-based DoctorDoctor service and the Western Australian Deputising Medical Service – the campaign is still ongoing.
Another example of an influential lobbying group is Pathology Australia, representing several big corporations, which converted their public “Don’t Kill Bulk Bill” campaign to a backdoor deal with the government to reduce the rent they pay to GP practices for co-locating their pathology collection rooms.
The response from the Royal Australian College of General Practitioners (RACGP) was that the proposed changes will create an anticompetitive environment, propping up multinational corporations that make hundreds of millions of profit each year, while GPs running small businesses lose funding on top of the ongoing MBS freeze.
The Australian Medical Association also made it clear that this proposal went too far, interfered with legitimate commercial arrangements that have been entered into by willing parties, and that it would damage medical practices.
A recent episode of Four Corners once again revealed the influence of the Big Vitamins industry, selling their unproven complementary products via community pharmacies.
Complementary Medicines Australia, a lobbying group representing the complementary medicines industry, argued on the program that, despite lack of evidence, there was a role for homeopathy and that “some consumers do find that it works”.
The Pharmacy Guild of Australia does not oppose the sale of unproven products, such as homeopathic ones, via community pharmacies.
The medical profession has been calling for more transparency about efficacy for years. RACGP president Dr Bastian Seidel said that the current retail business model of pharmacies, which allows products like vitamins and supplements to be sold to Australians, is inappropriate within the health care environment, and that these products must not be sold as complementary or alternatives to evidence-based medicines prescribed by a doctor.
Health consumers also have concerns: the Consumers Health Forum of Australia reiterated in a media release, following the broadcasting of the Four Corners episode, that the Therapeutic Goods Administration (TGA) does not include a check of the efficacy of most complementary products, and that a clear signal from the TGA about the therapeutic worth of these products is required.
There are other examples, such as the private health industry lobby and of course Medicines Australia, the pharmaceutical manufacturer lobby group. The Grattan Institute estimated that if the Department of Health kept vested interests out of the Pharmaceutical Benefits Scheme policymaking, taxpayers would save $320 million a year. As the Grattan Institute put it: “Seeking the advice of drug company lobbyists gave the foxes a big say in the design of the hen house”.
It appears that there is increasing pressure from a broad range of big corporations and lobby groups on the health care sector. I believe this usually does not improve patient care and, in some cases, will adversely influence health outcomes.
It is clear that politicians and decision makers are being heavily lobbied by these organisations, and the questions arise: will they be able to withstand these forces, and are they able to make decisions in the best interest of Australians – even though this may not always be popular?
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.
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 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.
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.
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.
Yesterday I bumped into Emeritus Professor Max Kamien at #GP16Perth, the annual conference for Australia’s GPs. It is always a pleasure to meet Max, who is a phenomenon in West Australia and beyond. Many general practitioners, including me, have at some time during their career been taught, tutored or assessed by him.
His long career as a medical writer started when he was a medical student: “I put a blowfly in a nitric acid bottle in the chemistry laboratory and was given two months of lunchtime detention washing chemistry retorts. My supervisors were Vincent Serventy, who wrote books about fauna and flora and Douglas Stuart, a larrikin writer of West Australiana. They introduced me to the joys of witchetty grubs and writing.”
“I was also the editor of ‘The Reflex’, the WA medical students magazine. The Medical School registrar burned it. It is now a valuable collectors item. One article pointed out that most of the Nazi medical experimenters were academics. It is still quoted in the world literature, which is not bad for a student publication.”
His book has received positive reviews. Charles Guest wrote in the MJA: ‘There is (self-deprecating) humour frequently but always compassion and instruction.” Robert Reid said in Medicus: “Professor Kamien has written an enjoyable, funny, insightful and yes, valuable book (…) with hardly an issue of life or medicine that is not examined or on which Prof Kamien doesn’t have a view.”
Max recommends two stories in particular: “Bill Reid; From inequity to virtue, which is about getting to know your feared adversaries, and the other is: Let me die like a dog. This is about my miserable failure as the long-time GP of a Catholic lady who got Motor Neurone Disease and, totally paralysed, lingered on for 10 years.”
“My book makes great Christmas presents for doctors, nurses and medical students. I have had only two negative comments. A colleague said he felt short-changed since he had read some of the stories before in Australian Doctor magazine. And some people who like to bend a two page book into a one page one have managed to split the spine.”
Lastly Max’s advice to new fellows is short but sweet: “Follow the last three paragraphs of the RACGP Oath of Fellowship.”
For the record, you might want to consider the whole oath.
Max is happy to provide his book to doctors attending #GP16Perth this week; he can sometimes be found in the exhibition hall. Make sure you get a copy if you haven’t already.
One of the big questions in primary care is: will the community pharmacy sector and general practice be able to work together without fragmenting care or duplicating services? If we don’t solve the issues and start to work as team, patient care will suffer.
For that reason, I’d like to take the Pharmacy Guild up on their suggestion to collaborate.
The relationship between doctors and community pharmacists is an interesting one: the two professions rely heavily on each other. For example, I find the advice and support from pharmacists invaluable when trying to solve difficult medication problems with my patients. Pharmacists also act as a ‘second pair of eyes’ checking my prescriptions.
Both doctors and pharmacists are highly valued by consumers and are, with nurses, in the top three most trusted professions.
On another level doctors and community pharmacists are often at loggerheads. Issues that come up time and time again are differences of opinion about the commercial aspects of healthcare, conflicts of interest with regards to prescribing and dispensing, and who does what.
In the eyes of many doctors, community pharmacy has gone off track with little connection at policy level with other primary care providers. Pharmacist will tell a different story. For example, some pharmacists – not all – seem to think that the main agenda of doctors is to protect their ‘turf’ – but there’s much more to it as I’ll explain below.
A while back I published an article on behalf of RACGP Queensland, drafted with input from a diverse group of academic and non-academic GPs. I outlined various issues with the Queensland immunisation trials, which have led to a change in Queensland’s legislation allowing community pharmacists to administer certain private vaccinations to adults.
The idea behind pharmacy vaccinations is to improve vaccination rates in people who don’t receive care through GP services. This sounds appealing from a public health point of view, but the impact on existing services has not been reviewed or taken into account during the trials.
Unfortunately the change impacts on the care delivered by family doctors and their teams. For example, my patients now regularly tell me that they’ve been vaccinated at a community pharmacy but have forgotten where, when and what exactly – and communication from the pharmacy is usually missing.
One of my frail elderly patients who came to see me for something else declined a government-funded influenza vaccination by our practice nurse because she was booked in to have a private vaccination at the pharmacy the following week, and felt she couldn’t cancel that appointment.
This goes against the argument that pharmacy vaccinations are only targeting people who don’t have a GP or people who fall outside the national immunisation program.
Moving services away from general practice also has an impact on opportunistic screening and prevention of health conditions by GP teams. So far this season I have been able to pick up several health problems in people who came in for vaccinations, including an aortic stenosis, pneumonia and two melanomas.
We are all connected
The main message here is that a change in one part of the health sector always affects the other parts. We’re all connected – this has nothing to do with money or turf but is all about providing high value, coordinated care.
It would have been nice if RACGP Queensland had been involved in the recent Queensland immunisation trials; we could have flagged and perhaps solved some of the many issues at an earlier stage.
Will the My Health Record fix these problems? Not entirely, because uploading data to an electronic health record on its own will not replace the need for good communication and collaboration.
In the article we also warned against introducing further changes to care delivery in community pharmacies (see image) that may result in poorly coordinated, duplicated or fragmented health services.
How to move forward?
After voicing our concerns in the article various debates occurred on this blog and in the pharmacy press, for example here and here.
The response from the Pharmacy Guild in Cirrus Media’s Pharmacy News however contained incorrect information:
This statement is wrong for several reasons: part of my work as a family doctor involves giving advice to travellers but I am not a proprietor of a travel clinic and I don’t profit from the sale of vaccines or other products.
So how to move forward from here? I thought this response from Tim Logan was more encouraging:
“(…) it profits society more for GPs to work with pharmacists, citing a presentation at the Australian Pharmacy Professional conference earlier this year by US expert Dr Paul Grundy, who demonstrated the benefits provided by a model which encouraged GPs to do so.”
I’d like to take Tim up on his suggestion to work more closely together and invite the Pharmacy Guild to meet with RACGP Queensland. I acknowledge that there are always two sides to every story. Let’s see if there is common ground and room for agreement on how our professions can work better together at policy level, without duplicating services or creating more fragmentation of care.
As said before, the RACGP remains committed to working collaboratively with other primary care providers and government to develop innovative and effective models of care such as the patient-centered medical home, and we strongly advocate for solutions that support genuine integration of care, not more fragmentation.
At the time of writing Dr Edwin Kruys was Chair of RACGP Queensland.
Last night’s undecided election results raise many questions – and doctors will say: we told you so.
Family doctors have made it very clear during the lead-up to the federal election that it’s crucial for governments to invest in primary care to keep Australians well and out of hospital.
But not only that, during the longest election campaign in Australia’s history, GPs around the country have had discussions with millions of patients about the future of their healthcare.
Looking at the outcome of the election night, it seems that voters have taken the message to the polling booths.
Wealth should not affect our health
The day after the federal election date was announced, the Royal Australian College of General Practitioners (RACGP) launched the You’ve been targeted campaign, warning people about the looming higher out-of-pocket costs, which have already become a reality.
The aim of the campaign was not to increase health corporate profits or fill doctors’ pockets, it wasn’t even a political campaign – it was all about the message that the Australian people must be able to visit their doctor when they need to.
Doctors called on a newly elected government to invest in quality and sustainable general practice to strengthen patient services.
“Our first and foremost responsibility is to our patients,” said RACGP President Dr Frank Jones, “and this is really the message from the College in the campaign, because this is about the fact that we cannot sustain quality general practice under the present Medicare freeze.”
Posters went up in GP surgeries, messages were printed at the bottom of prescriptions, TV ads were aired and there were 2340 syndicated media stories featuring the RACGP on national TV, print and radio, and in medical and consumer media outlets across all formats.
The Australian Medical Association (AMA) followed suit and threw its weight behind the issue, and shortly after many political parties made health a key focus during the election campaign. The policy shift by Labor to lift the Medicare freeze and fund chronic disease management by general practice teams was welcomed by many.
What should happen next?
Whatever the outcome of the election will be, the new government would do well to sit down with GP leaders and develop a long-term plan to strengthen primary care. The message is simple and supported by abundant evidence: strong primary care keeps people well and out of expensive hospitals. Investing in general practice patient care pays off!
Dr Frank Jones: “The RACGP is seeking progressive health reform and a genuine commitment to the future of our healthcare system from our political leaders and we are committed to discussing funding models for a sustainable and effective primary health care system.”
As GPs around the country are moving away from bulk billing, health minister Susan Ley has already indicated she is prepared to look at a medical home model. The proposed appointment of a National Rural Health Commissioner and commitment of the Coalition to pursue a National Rural Generalist Training Pathway is another positive sign.
However, the medical home is more than a hospital avoidance project. “In a patient-centred medical home, patients have a stable and ongoing relationship with a general practice that provides continuous and comprehensive care throughout all life stages,” said Dr Jones. “This model is the most cost-effective way to address the needs of patients, healthcare providers and funders.”
Part of the future plan should be the continuation of high quality primary care research and the introduction of non-face-to-face patient services such as video consultations to improve access to family doctors and to transform Australian primary healthcare to the digital age.
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:
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.
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.
When I was preparing this session I thought I’d start by telling a joke:
Five doctors went duck hunting one day. Included in the group were a general practitioner, a pediatrician, a psychiatrist, a surgeon and a pathologist.
After a while, a bird came winging overhead. The first to react was the GP who raised his shotgun, but then hesitated. “I’m not quite sure it’s a duck,” he said, “I think that I will have to get a second opinion.” And of course by that time, the bird was long gone.
Then another bird appeared in the sky. This time, the paediatrician drew a bead on it. He too, however, was unsure if it was really a duck in his sights and besides, it might have babies. “I’ll have to do some more investigations,” he muttered, as the creature made good its escape.
Next to spy a bird was the sharp-eyed psychiatrist. Shotgun shouldered, he was more certain of his intended prey’s identity. “Now, I know it’s a duck, but does it know it’s a duck?” The fortunate bird disappeared while the fellow wrestled with this dilemma.
Finally, a fourth fowl sped past and this time the surgeon’s weapon pointed skywards. BOOM!!
The surgeon lowered his smoking gun and turned to the pathologist beside him and said: “Go see if that was a duck, will you?”
The tribal jungle
Two years ago our keynote speaker was the amazing Dr Victoria Brazil, emergency physician and medical educator from the Gold Coast. She spoke about tribalism in our profession and said:
“I think we actually work in a tribal jungle in healthcare.”
She was right. We make jokes about the characteristics of the other tribes, like I just did, but tribalism is still one of our biggest challenges today. We are concerned about fragmentation in healthcare – but what about the divisions within our own ranks?
Part of what makes general practice attractive is its diversity, but it is also a weakness. Think, for example, of the stereotypical dichotomies: generalists vs partialists, private practice versus corporates, rural versus metropolitan etc.
I’m not saying we should be one big happy family, but why not focus more on what we have in common?
There is hope: participants of groups like United General Practice Australia and, here in Queensland, the GP Alliance, have shown a desire to put aside tribal differences and work towards common goals. This is a start, and initiatives like these must further strengthen the voice of general practice in the near future.
Investing in general practice
With the Federal Budget due to be handed down this coming Tuesday, this weekend also serves as a timely reminder of the RACGP’s advocacy campaign to reverse the freeze on Medicare rebates. As part of our pre-budget submission to the Federal Government, we outlined 4 key strategies that will improve quality-led patient care.
In order to provide quality healthcare services, MBS rebates must be in line with the cost of doing so. More than 80% of the Australian population is seen by GP’s each year but only 8% of Government healthcare spending is allocated to general practice.
New data presented in the flagship report from the National Health Performance Authority released this week, shows that people who do not see a GP have a 30% higher chance of visiting an emergency department.
Investment in primary care will result in long-term health savings and reversing the freeze on MBS indexation is a must. The College will continue to represent our members and lobby the government on this very important issue.
The theme of this RACGP Queensland Conference is ‘the future’. So here’s a challenge for you:
You don’t have to go duck hunting with your colleagues, but what can you do to reduce tribalism?
If you decide to take up this challenge, do one thing, one little thing, and start this weekend while you are amongst your peers.
If we want the future to be different, if we want to see different results, we should do things differently.
The passionate country doctors featuring in these videos with their patients are great examples for rural general practice. Warning: After watching the interviews you may feel the sudden urge to pack your bags and move to the country.
Dr Ken Wanguhu: “Being a GP has taught me that there is a lot more to medicine than disease… It goes beyond the disease to the patient and their family and to the community, and that’s general practice.”
The second video features Dr Mel Considine and her patient Phil from rural South Australia. Phil: “And the first thing I remember was this lovely lady leaning over me, and she said ‘I’m Doctor Mel, the duty doctor today, and I’m here to look after you.'”
When I got back from a family camping trip this month I noticed the government had made important eHealth announcements shortly before Christmas Day. In summary, the news was that the government is going ahead with its plans, despite objections from the RACGP, AMA and others.
Practices will miss out on their IT support payments if they don’t upload patient health summaries to the PCEHR (now called MyHealth Record). These IT support payments were originally introduced to make sure practices have up-to-date computer systems.
The Department must have known that GPs are usually not employed by practices and that most are ‘contractors’. This effectively means that they run their own independent businesses within a practice. Stopping payments to the practice does not directly affect their hip pocket unless they own the practice.
This seems to be bad news for business owners. The strategy could affect the quality, safety and security of the medical IT systems – which is not good for patient care. The question is: will doctors be using the eHealth system more often as a result of this change?
The wrong tool
Dr Nathan Pinskier, chair of the RACGP expert committee for eHealth and Practice Systems was quoted in Australian Doctor magazine saying: “Practices can’t compel GPs to upload these health summaries. So the practice faces losing the whole payment. [The government] is using the wrong tool. If you want to fund GPs to do this work, then think about a separate MBS item number.”
Some of the responses from doctors to this article give a rough idea of what the general opinion seems to be:
“I will not participate in this ill-considered e-health scheme until the legislation catches up to make the e-health record ‘fit for purpose’ as a clinical tool for clinicians and not just as a data mine for Government auditors.”
“All this decision does is confirm that Ms Ley and Dept of health with their rhetoric of conciliation and discussion in consultation with primary care are nothing but a load of lies and an insult to primary care.”
“Then there will be all the vultures, like insurance and finance companies, who will start circling, seeing getting access (by a degree of sophisticated patient blackmail) to this information as a great cheap way of getting what they want without having to pay us for a report.”
“The daily GP practice number median (50% more, 50% less) is 40 patients a day (Medicare data). That is a practical average of 8 – 10 minutes a patient. If accessing, discussing, uploading adds an extra 5 minutes a patient, that will be a reduction in bulk billed cash flow of 33%. Overheads will remain the same. Can you afford it?”
Judith Sloan, economics journalist at The Australian Newspaper, wrote: “It’s a type of childlike optimism – the idea that governments can achieve lots of good things through the creation of large-scale, all-embracing information technology platforms.”
“(…) But rather than ditch what is an incredibly wasteful commitment of taxpayer money, the current government has decided to press on and switch from an opt-in arrangement to one in which patients are forced to have a PCEHR unless they object.”
Dr Pinskier in Australian Doctor magazine: “We have a view that there is a role in the 21st century for a consumer health record. But it’s unclear to doctors whether the MyHeath record is a consumer record, a clinical record or hybrid.”
“(…) It is still unclear what real purpose it serves. (…) It was a good idea a decade ago but now we have cloud-based technologies. We are moving away from Big Brother data systems. Is [the MyHealth system] still relevant?”
The AMA has also indicated that it’s unhappy about the changes to the eHealth incentive structure. In the meantime, opt-out trials are being prepared, which are another attempt to push health consumers and practitioners into using the heavily criticised system.
The other issues we can of course expect is that the targets will be increased but the incentive payments to practices will decrease over time. Not something to look forward to in the current climate of Medicare rebate freezes.
There are oncerns about the secondary use of the data in the record as well as excessive penalties for health providers. Monash University researcher Juanita Fernando recently wrote in a response on this blog: “As we have known for some time, the MyHR legislation explicitly allows the data to be used for reasons other than health care. GPs have seemed to be blissfully unaware that their own medical records may legitimately be accessed by any and all of their peers or colleagues.”
“Under the current MyHR ‘opt-out’ paradigm, everyone will actually have a record created, even if they opt out, only it will be ‘hidden’ on opt out. The security of this hidden record is not guaranteed. We seem not to have the option to have it not created.”
Secondary use of data, or the use of patient health information for purposes other than clinical care, is usually not the first thing people think of, but the recent revelation that over 60 organisations, including AHPRA, have applied to access our metadata for various reasons, is a reminder that this could be reality soon.
What the College says
RACGP President Dr Frank Jones said in a senate submission: “Penalties which may be applied for the misuse of MyHealth Record appear excessive and unnecessary and will greatly deter use by busy general practitioners. Provisions for penalties already exist within the Australian Privacy Principles so it is not clear why there is a need for additional penalties, civil or criminal, to be imposed.”
As everybody knows, the main thing that has been missing all along is genuine engagement with GPs. The RACGP submission to the Medicare Benefits Schedule (MBS) Review Taskforce hit the nail on the head and the government would do well to heed this advice:
“Meaningful engagement between the Federal Government and the healthcare sector is needed to address these issues and for myHealth Record to be successfully adopted.
The submission continued: “Meaningful use of MyHealth Record relates to safety, quality, communication and healthcare outcomes – not data collection. Characterising myHealth Record as a data source rather than a tool to support clinical practice is of concern to GPs, who will be the primary users of the system (…).”
All in all I’m becoming less and less optimistic about the future of the national e-health database, and it seems I’m not the only one. There are many alternatives but sadly the government is pushing ahead and, whether it does so on purpose or not, it seems the project is sadly getting closer to the edge of that big, overhanging cliff. The analogy with lemmings comes to mind.
Do you know that situation – usually at a party – when someone tells you what they do for a living, and mention a cool sounding job description like ‘product innovation manager’ or ‘advertising account executive’? I always want to know: what does that mean and what do you actually do?
Well, people never ask me what I do when I say I’m a GP. Instead, they usually tell me what their GP does. Or did. Or said.
Everybody always knows what I do, and that’s not surprising because the Australian general practice statistics are mind-blowing: Over 134 million GP consultations take place each year. Every year almost 9 out of 10 Australians make at least one contact with a general practitioner.
“Mothers, children, the elderly and those with chronic conditions, such as diabetes, asthma and hypertension, have many more contacts than that. As a result of these personal contacts everyone has a view about general practice. Ministers of Health have been known to base their views about general practice on their contact with their own GP.
I’m privileged to have a job that’s smack-bang in the middle of life. One could indeed argue that we’re specialists in life, as we deal with just about everything: mental health, paediatrics, cancer, skin disorders, respiratory problems, grief, heart failure, domestic violence, emergencies, pregnancy, end-of-life care, immunisations, screening… you name it.
The latests RACGP commercial tells the story of diversity – the diversity of GPs, their patients and their conditions. I love the commercial because it captures in 60 seconds the wide range of issues people bring to the consulting room of the family doctor.
So if you want to find out what really happens in my office, have a look at this video.
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:
Practices will have a better understanding of their patient population and can better tailor services to the needs of their community.
A stable and enduring relationship between a patient and a GP has a positive impact on health outcomes.
It will benefit prevention and management of chronic diseases.
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.
I recently participated in a webinar organised by the Department of Health. It was supposed to be a consultation about the uptake of eHealth.
It went something like this: “We want to gain feedback from GPs about how we can get you to use the eHealth. This is how we’re going to do it; we’ve already organised training and we’re kicking off after the Christmas break. But before we start this session you must know that we cannot consider other options or timeframes.”
I was speechless. Literally – as I was not allowed to speak. I could only send little text messages via the closed online question platform. I was unable to see the feedback from other online participants.
For years health providers have repeatedly said, if you want to make eHealth a success please take us with you.
The government is talking about new incentive payments to practices, ‘refreshed’ training programs and opt-out instead of opt-in, but there is little mention about improvements that make health providers want to use the PCEHR (now called ‘My Health Record’).
It is concerning is that the current plan mainly encourages uploading of documents. What should be facilitated is safe and more efficient care for our patients. At the moment it seems to be all about the number of uploads to the system. I cannot help but wonder what higher level performance indicators are at work here.
Any incentive has to be effective at provider level to create behavioural change. In other words, we must encourage individual practitioners to use eHealth, not just organisations and practices.
It is no surprise that the government failed again to enlist support from the profession. In its submission to the Department of Health, the RACGP wrote:
“(…) the RACGP cannot support the proposed mandatory requirements for the uploading of a specified quota of clinical documents to My Health Record. Meaningful use is not just uploading information to My Health Record, and nor is uploading information an acceptable starting point for meaningful use. Meaningful use relates to safety, quality, communication and healthcare outcomes – not merely numbers.
E-health experts have warned that the system is still unsafe. For example, some software programs merge medication dose and instructions. Others have warned that the uploaded clinical information does not always arrive in the My Health Record database.
Then there are the unanswered medicolegal issues. As I said in MJA Insight, I would be happy if the data in My Health Record was used for other purposes such as disease surveillance or even feedback on my clinical management but, in the end, it is the patient’s record and they must have a say in it. A proper consent procedure is essential for any use of PCEHR data outside individual patient care.
It appears the system operator is currently authorised to collect information in individual health records for law enforcement, health provider indemnity insurance cover, research and public health purposes, and as required or authorised by law. This process should be more transparent with a better explanation of what it means for both patients and providers.
Removing the need for provider participation agreements is needed as these documents are very one-sided. It is not clear to me what this will mean for the liability of organisations, practices and individual practitioners.
A failing strategy
It is challenging to have a discussion about incentivising uptake of eHealth when there are so many unknowns. It’s like trying to sell a house that’s still being built and everyone knows there are construction issues. Pushing people to live in the house does not make it a safer or a better building.
The RACGP warns against hastily implementing incentives and advises the department to wait for the outcomes of the Primary Health Care Advisory Group review, the MBS review, and the opt-out trials which are due to start.
Once the identified problems with My Health Record have been addressed and resolved, the RACGP believes that uploading of patient information to My Health Record would be best supported by a practitioner incentive payment (SIP) or an MBS rebate.
It will be interesting to see the response from the department. I’m afraid that history will repeat itself: they’ll go full steam ahead, only to discover in one or two years time that the strategy didn’t work. What do you think?
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.