John Dwyer. The structural reform of Medicare rather than its funding is the real challenge.

Aug 20, 2014

Part 1; The model of primary care we need for contemporary Australia.

For months the federal government has been telling us that a mandatory co-payment for a visit to our GP was essential to afford the $19 billion we currently spend on Medicare each year and projected increases. There would be an added benefit in that the payment would send a price signal to remind Australians that such visits can no longer be free. Too many of us are visiting our doctors too often! Additional revenue would be generated by a seven-dollar co-payment for prescriptions, pathology and imaging. Given the above propositions it is confusing to say the least that our government now plans to put every penny raised by these co-payments into a medical research fund that should eventually be the largest such fund in the world. Perhaps Medicare spending is not so unsustainable after all. International evidence tells us that we should be spending more on Medicare funded services to reduce total health expenditure. How would this work?

Medicare needs to evolve from a universal insurance entity that pays doctors bills to one that funds clinicians who will provide a specific model of care. An uncapped payment of doctors “fees for service” not tied to any health outcome measures is not a satisfactory way to use taxpayers health dollars. World wide the move is to achieve better health outcomes more cost effectively by focusing on delivering  “Integrated Primary Care” (IPC) available from a person’s “Medical Home”.

In our doctor centric health system, Australians visit their GP when they have a problem. They do this, on average, seven times a year. Many should go far more often to improve their health and many who need care the most visit their doctor infrequently. The burden associated with chronic and complex and often-incurable disease, compromises the quality of life for too many Australians, dominates the care requirements of many GP practices and cost us all a fortune. Given that so much of this suffering is preventable why is their so little emphasis on prevention and the provision of the health infrastructure to facilitate prevention? Only 2% of the annual $180 billion health spend in Australia involves prevention.

At the other end of the care spectrum our Primary Care system lacks the infrastructure to care for many in the community and thus avoid the need for hospital care. We have more inpatient “overnight” beds per capita than any other OECD country and yet at the moment we need more. We hear almost daily about access problems for patients stuck in Emergency Departments because there is “no room in the Inn”. What our government does not seem to appreciate is that annually some 600,000 of these admissions (cost $ 30 billion) could be avoided with an effective community intervention in the three weeks before eventual hospital admission. The University of Melbourne studied this matter and found that each year seven million bed days are consumed by avoidable hospital admissions. We spend more than $140 billion on public hospital care each year, seven times more than we spend on Medicare. If we had one level of government funding health care instead of our destructive jurisdictional division of government responsibilities (States for hospitals; Canberra for Primary Care) we would readily spend more on Primary Care models that would reduce the need for so many hospital beds.

The preferred model of IPC involves establishing a practice (Medical Home) populated my clinical teams, (doctors, nurses, allied health professionals a dentist etc) in which patients enrol with the understanding that they and the team share the responsibility for keeping them well and providing the best possible care when they are ill. The psychology of enrolment is all-important as is the principle that the most suitable members of the team will care for one’s current specific needs. Health maintenance is regarded as an active endeavour. This is evidence-based personalised care. Health literacy and lifestyle analysis, and support for needed changes, might be facilitated by specialised nurses and nutrition experts. Continuity of care improves the chance of early diagnosis and treatment of problems that could become chronic (early signs of adolescent mental health issues for example).

Team management of chronic conditions with a team based case manager and care for fragile members of the practice in the community by appropriate clinicians to reduce the incidence of hospitalisation are also important initiatives. There is one medical record and rapid access to team members is facilitated by IT connectivity.  Well-established IPC units in other countries have reported up to a 42% reduction in the need for hospital care. Such a model makes best use of the unique skill set different health professionals possess, so different from our current “silo” mentality that makes the integration of an individual’s care so difficult. So successful is this model that already universities around the world are concentrating on moving to inter-professional learning curricula, “Team learning to prepare for team practice”.

This is “Managed Care”, a term that conjures up in the mind discredited model of care available in the US. There are three players making decisions in much of the US system, the patient, the care team and the patient’s insurer. The latter, famously documented in Michael Moore’s documentary on the issue, all too often interfere with care plans even vetoing them on grounds of affordability. We need to think carefully about the wisdom or otherwise of allowing our private health insurance industry (PHI) to cover members primary care expenses. I would be less worried about interference in care plans here than in the likely creation of a “two tiered” primary care system in which those who can afford PHI would enjoy much better primary care than those who could not. The resulting furtherance in the inequity palpable in our current system would not only be un-Australian but expensive.

Part 2 of this series will be posted tomorrow. It covers the necessary changes in the health workforce. 

John Dwyer is the Emeritus Professor of Medicine at UNSW.


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