Instead of tinkering around the edges of Health Reform in Australia,and dodging meaningful revision of the Medical Benefits and Pharmaceutical Benefits Schemes, all Federal politicians and leading clinicians could be debating two issues which would have significant effects over the next 20 years. Currently thousands of clinicians (doctors, nurses, allied health and other healthcare providers) are despairing of meaningful healthcare and workforce reform by our Federal and State politicians.

Remuneration

It appears that, over recent years, other countries have been looking at widening the choices of remuneration to healthcare providers. Why is Australia not doing so?

The US Secretary of Health and Human Services wrote an article earlier this month in the New England Journal of Medicine on Setting Value-Based Payment Goals . She was building on health reform initiatives suggested by clinicians and health economists. They stressed that the current US system was too expensive and out of date. She put forward a plan to have 90% of all Medicare fee-for service payments and 50% of Medicare payments tied to quality or value through alternative payment models by the end of 2018. Suggested alternative payment models included accountable care organizations and bundled-payment arrangements. She outlined three strategies. First incentives to reward hospitals and healthcare providers for delivering high-quality patient care with advanced primary care medical-home models and introducing new models of bundled pay for episodes of care . Second, greater integration of practices and greater co-ordination among providers with more attention to population health. Third, a greater adoption of electronic health records (EHR)although she states that in the US 78% of physicians and 94% of hospitals now use them. She also stresses a greater commitment to transparency of data on costs of healthcare services to enable consumers to make better informed choices when selecting providers.

New Zealand has, for some years, moved away from fee-for-service alone to include universal capitated funding, patient co-payments and targeted fee-for-service for specific items.

The French Minister of Social Affairs and Health writing last year in the Lancet talked of remuneration reform. She wrote that because of evidence of substantial and increasing health inequalities, the payment system to providers had been reformed, inter-disciplinary team practice fostered and health information strengthened to help consumer choice. Alternative models to FFS included capitation and incentives to providers to avoid unnecessary care and higher valued services.

Who would look at these options in Australia? Our politicians and health bureaucrats have singularly failed to do so. Perhaps we need an independent body?

Healthcare Reform Commission

Increasingly there are calls to establish an independent, professional and ongoing body to advise the Australian community on long- term issues in healthcare reform. Such a healthcare reform commission would need to be completely independent like the Reserve bank. It could look at and advise on many major health problems. John Menadue suggests a pilot joint Commonwealth/State initiative to end the dichotomy of funding between the two administrations which encourages cost-shifting.

In Australiawe are blessed with outstanding public health academics, health economists and leading clinicians. They could lead us into a sustainable future, gaining the support of clinicians and the public.

Kerry Goulston is Emeritus Professor of Medicine at Sydney University.