John Dwyer. The structural reform of Medicare rather than its funding is the real challenge.Aug 21, 2014
Part 2: Attracting the future work force needed to provide Primary Care.
There is another imperative for introducing Integrated Primary care (IPC),the new model of primary care described in part one of this review; the recruitment of the next generation of GPs.
Recent surveys of the career intentions of medical graduates show only 13% are interested in a primary care career and only 13% of them have any interest in working in rural Australia. They see that 70% of GPs do not want to be tax collectors for the government and note that the Medicare rebate for a standard occasion of service has been reduced to $31.60. GPs are specialists aren’t they? This is not attractive remuneration especially when socio-economic circumstances leave 80% of GPs with little option but to bulk bill their patients. This in turn leads to “turnstile medicine: unsatisfactory to both practitioner and patient, and the well documented poorer health outcomes associated with this form of practice. Many GPs want to move away from the “fee for service” model and try to do so by joining the “corporate” GP world. There many are dissatisfied with the model of care imposed on them.
On the other hand young doctors considering a career in primary care are attracted to the IPC model; after all they have seen team medicine as a normal activity in our hospitals. In New Zealand 85% of GPs have voluntarily abandoned fee for service payment in favour of salaried or contractual payments. The same is true for 65% of US GPs. Currently about 65% of GP practices in Australia feature three or fewer doctors. However good the care on offer these are not strong economic units. IPC practices, established as companies with community representation on their boards, offer great flexibility and the chance for the clinicians working in the clinic to develop equity in the business. This is important as our GP specialist on average earn far less that many of their colleagues.
IPC Clinics also facilitate the introduction of other urgent reforms. Pre-agreed per capita funding for patients with defined chronic conditions, if established competently by peer review, offers opportunities for better outcomes to be rewarded. There is an excellent opportunity for the planned replacement of “Medicare Locals” with “Primary Care Networks” to facilitate the introduction of IPC into Australia. Current discussions suggest that there are to be 21 PHNs established across the country. There mission statements are yet to be clearly defined but the better integration of patient care will be a major focus. By sponsoring geographically local sub-units (Lets call them Primary Health Care “hubs”) within defined Local Hospital Districts, affiliated IPC clinics in the area could be provided with the centralised assistance needed to better operate their care model. IT expertise, bulk purchasing, continuing education resources, in house review of new drugs, meeting with local hospital clinicians re patients frequently readmitted to hospital and many other initiatives could be available. Although the review commissioned by the government recommended that PHNs not engage in clinical work, a number of primary care hubs in New Zealand offer acute care services and even run observation wards where patients can be treated for many hours while a decision re the need for hospital admission is made.
So can we afford to introduce these structural reforms? The reality is that we cannot afford not to. Hospital expenditure dwarfs Medicare expenditure and increases more rapidly. The future of affordable quality hospital care is inextricably linked to better primary care reducing the demand for hospital services.
IPC would provide us with many more healthy Australians whom we are predicting will need to work longer .A 40% reduction in avoidable hospital admissions would save us at least $12.5 billion a year and reduce much personal suffering. It can be estimated that these results would require an additional $5-7.5 billion a year being spent on Primary Care by the time the changes are fully introduced nation wide. Diverting the dollars spent on subsidising private health insurance would almost supply the money needed but there are many other savings that would follow structural reforms. Increasing the level of health knowledge among Australians would see them stop looking for health out of a bottle and provide the almost $3 billion they spend on unnecessary supplements, vitamins and “good bacteria’ for better primary care help. Better attention of many doctors to the need for an evidence base for the care they give could save $20 billion spent on low value or no value procedures. Nine departments of health for 23 million Australians comes with duplication costs of at least $3 billion.
The reality at this time of course is that the Abbott government has shown no interest in structural reform for our health system. The peak advisory body on Prevention has been discontinued. However we must continue to engage the community in a discussion of what they want from their health system and alert Australians to the benefits of IPC. Adequate penetration of the new IPC model with all the structural and cultural changes required would take at least a decade. We can all live with this journey providing the destination remains clear. The journey needs public support and bottom up implementation from within the health professions themselves. Politicians need not fear the slowness of progress within the election cycle. These reforms are achievable as we can note from numerous successful implementations elsewhere. The community will applaud the political leadership that commits us to the journey and supplies the infrastructure to drive the initiative. Ideally a transition authority would be established to guide us on the journey. The challenge now is to find that political understanding and leadership that will help us take that “first step” that must start all journeys.
John Dwyer is Emeritus Professor of Medicine UNSW