JOHN DWYER. Health Reform’s “Holy Grail”;Medicare must fund the “team Medicine” approach to Primary Care.

 

Surely my disgust at the Coalition’s decision to spend more than a billion dollars re-opening the Christmas Island detention centre to make sure that none of those nasty murderers, rapists and paedophiles ever get to real Australia for any medical care, is widely shared. There is so much real health that could be purchased with those dollars.

It’s election time in NSW and billions of dollars are being promised to upgrade existing hospitals and build new ones. Many of our hospitals desperately need modernising and and reequipping with the latest, often invaluable technology, that improves cost effectiveness and health outcomes. But what about the hospital system’s bed capacity?

The problems associated with reducing road and hospital congestion are similar. We know that building more roads to ease traffic snarls will result in many more cars carrying one person being bought to use the new facilities; “Nature abhors an empty freeway”.We already have more overnight beds per capita than any other OECD country and yes, today we need more. Many public hospitals report huge annual increases in the demand for their beds.

Too many emergency rooms cannot meet the minimal standards for the timeliness of treatment for seriously ill patients. It’s not unusual for ED statistics to report a 10-11% increase in annual attendance figures. Analysis shows that patients are older and sicker and predominantly have medical not surgical problems. So today we need more beds but the demand will continue unless we “get more cars of the road”. The future of timely, quality, hospital care will depend in reducing the number of people who need hospitalisation with the majority of hospitalised patients being in house because their problems can only be addressed in a hospital (e.g. patients needing surgery, intensive care, coronary care, a stroke unit etc). So in the jurisdictional nightmare that we live with in Australia, States spend billions of dollars on hospital care while the Commonwealth spends virtually nothing on prevention strategies that would produce a healthier population and eliminate the more than 650,000 annual admissions to hospitals that could have been avoided if Community and Primary care was better resourced. We will see an avoidable and unacceptable increase in the % of GDP spent on health if we continue with current policies.

The last Federal election featured a scare campaign from Labor suggesting that the Coalition was planning to dismantle Medicare. That was not the case but the community response made it clear that Medicare is politically sacrosanct. But Medicare is in danger because of its internal failings. Medicare is failing to address the health imperatives of contemporary Australia. We spend 20 billion dollars a year on the services Medicare provides, Primary care from our GPs, some community care, pathology and imaging, some allied health services and subsidies for prescribed drugs. GP services result in the Commonwealth being billed for seven billion dollars a year. Over the last thirty years our use of pathology test and imaging services have grown by almost 80% and we now visit our GP more often. Obviously we benefit from what Medicare currently pays for but increasingly what we need from our taxpayer funded universal insurance scheme is simply not available.

Our Primary care system is doctor and illness centric and not resourced to improve the communities health literacy with an emphasis on preventing illness. We go to the doctor because we have a problem not to help us stay well. Current care models have failed to prevent millions of Australians developing chronic diseases many of which are lifestyle related. 50% of us over the age of 50 have a chronic problem and as we age its common for individuals to have a multitude of chronic problems all needing simultaneous care. (High BP, Diabetes, Obesity , chronic arthritis etc.) Optimal management requires help from a range of health professionals and we are notoriously bad at integrating that care in a patient focussed way. (The biggest single complaint from healthcare consumers).We live longer but the extra years for many are not quality years. We are told we will need to work beyond current retirement norms if we are to afford social security in our old age so we need to be healthier longer.

Our GPs are specialists but not well remunerated when compared to other specialists. Government can and does, place a freeze on Medicare payments to GPs and this together with the low fee for an occasion of service ( less than $38.00, what will your plumber do for that?) provides an incentive for doctors to focus on increasing the numbers of occasions of service rather than the quality of those encounters. Only 16% of medical school graduates are considering a career as a GP.

Given these problems there has been ever increasing interest on moving away from a fee for service payments systems to one where GPs are paid a fixed sum based on the complexity and the time needed for optimal management of a specific patients problem(s). Hospitals in Australia now receive “activity based funding” for the services they provide. For example actuarial studies have examined how much it should cost for an efficient hospital to remove a gall bladder. Various weighting factors are applied for unusual circumstances and then hospitals know what they will receive for that service.

Writing in “The Conversation” recently , respected health economists Jane Hall and Kees Van Gool argued the case for swapping fees for service payments with “bundled payments”. They write;

“Under a bundled payment, the patient’s GP clinic would be paid a lump sum to ensure the patient receives all the services they need. This includes consultations, health checks, blood tests, physiotherapy, dietetics, patient education, and so on. The GP would have more control over how each of those services is delivered”.

I have been arguing for such a system for sometime but with some additional features. At the moment we do not have outcome data that would allow us to judge a GP’s competency and cost effectiveness. We may like our GP but we don’t have data on the quality of service offered. In the bundled payment model a condition for the payment would be that health outcomes are measured and documented for the payer to study. The Conversation paper suggest that GPs could subcontract for services not available within the doctors practice. Far better would be the model I have described herein on a number of occasions where it becomes normal for primary care practices to be constituted by a team of health professionals including those who could monitor patients in a community setting who otherwise would be likely to require a hospital admission. (The “Medical Home” model). This is the future as pursued in 11 OECD countries. This is “Team Medicine” and this needs to be funded by a contemporary Medicare.Just as was the case with Activity Based Funding for hospitals, much analysis would be needed  to derive the appropriate fee that would be paid for a “bundled” set of services.

I hope it will be obvious that to drive forward all the structural reforms needed, we will require the establishment of a “Health Care Reform Commission” established by COAG and thus enjoying support from the Commonwealth and all States. Labor is promising to establish such a Commission, a very important promise receiving zero publicity so far as politics rather than policies continue to dominate all media re the upcoming election.

Professor John Dwyer, Emeritus Professor of Medicine UNSW and founder of the Australian Healthcare Reform Alliance.

print
This entry was posted in Health, Politics. Bookmark the permalink.

4 Responses to JOHN DWYER. Health Reform’s “Holy Grail”;Medicare must fund the “team Medicine” approach to Primary Care.

  1. Donald Kent says:

    It should be further recognised that the team approach and medical homes ideas will further fragment health care even while it improves the delivery of appropriate care to those who will benefit from it. This should be understood, accepted and built on rather than papered over while trying to get the ideas accepted and implemented.

    Fragmentation of health care is not necessarily an evil and there are no simple solutions, but it needs to be openly discussed, debated and managed.

    Issues to consider are:

    – provision of care to areas (both urban and remote) not equipped to provide such care

    – provision of care to communities not able to receive such care (an obvious example is a community with cultural or language differences but one can foresee a discrimination of care provision and access to the health dollar even in something as simple as those who live in their own homes and those who cannot do so)

    – provision of care to patients who do not fit into defined categories of care and their consequent difficulties in accessing such funding and care eg, a patient with a stroke requires a significantly different type of team care and medical home requirements to a patient with a heart attack or recent stent or bypass. And to make this consideration even more complex, these approaches often have conflicts in the most appropriate care, which is why the dumbing down of GPs’ work and care to satisfy appropriate outcome measures usually end up with more problems. A common example is the acute stroke patient with a history of ischaemic heart disease juggling with questions about polypharmacy, falls risk, risk of major bleeding, early rehabilitation and exercises, while attempting to make their homes safer, dealing with a team of new faces all giving advice that costs too much, and putting pressure on them to give up their privacy, individuality, independence and choice.

  2. Donald Kent says:

    Some basic concerns to address with this team approach / medical home approach are:

    – unintended consequence on provision of acute care in the community; when the money drives GPs to provide chronic care the capacity to provide acute care will fall – not just in the number of GPs and consultations devoted to providing such care but also in the education, training and standard of care provided in subsequent decades as new GPs trained in providing care under the new model replace older ones

    – this will put pressure on the hospital system, which would be worse than the problems in the NHS because of the separate state and federal funding to hospitals and GPs respectively

    – recruitment of GPs will be even more difficult as medical schools and hospitals provide 4-10 years of training in ‘hard’ medical care, putting emphasis and prestige on such achievements and work while actual GP work under such a model will become increasingly ‘soft’, and ultimately hollowed out and replaced by individuals and corporations when the work can be undertaken sufficiently by them; this is already happening, and contributes to the ‘crisis’ the team approach /medical home is trying to solve

  3. Donald Kent says:

    The team approach and medical home approach provide a theoretically viable and simple solution to health issues that benefit from such approach. Health care is unfortunately anything but simple. I have come to be very wary of any one-size-fits-all solution to health care and funding, especially when the ideas and solutions are being put forward and driven by politicians, economists, academics and generally any one but the doctors who actually work in the system. Otherwise we will end up with another very expensive white elephant like the MHR where failure in the UK was ignored or deliberately adopted in Australia, the parallels for which we can see in the UK’s capitation and contracting of GPs in a similar form as put forward by The Conversation article and this blog post, and consequent effects on the NHS.

    The ALP has had as many stumbles as the LNP in the area of healthcare, unfortunately, with Tanya Plibersek’s reign as health minister particularly significant to one’s consideration in the upcoming election and any shock-and-awe Labor policy on health. While Nicola Roxon oversaw more damage to primary care and health care in general, she has retired so the spotlight falls on Tanya Plibersek.

  4. Evan Hadkins says:

    How do bundled payments (for the treatment of sickness) lead to a shift to a focus on health?

Comments are closed.