I understand that at the recent National Conference of the AMA there was general support for a move to help funding systems other than just fee-for-service. Ross Kerridge examines this issue below. John Menadue
Healthcare Heroes. How to reward GPs for what they do best: a hospital specialist’s proposal
There is an old saying in healthcare: – “If the GP is good, a specialist may be able to help. If the GP is bad, nothing will help.”
The Junior Doctor has asked my advice about a 78 year old woman who has been booked for a hip replacement next week. She has the features common for her age – touches of heart disease, diabetes, emphysema, and her husband died three years ago. Children interstate. She’s maybe a bit forgetful. Not really sure about her regular medication, but says she is still living independently. “Seems a nice old lady and quite active but it’s a bit hard to be sure from just meeting her today.”
Preparing her properly needs more information. So does planning her postoperative care. The GP is the key to sorting it out….. “OK, who is her GP?” I ask.
“She doesn’t have a regular GP any more. She goes to the 24-hour medical centre. We have two different versions of her medication and little information about her visits to specialists. She’s a bit vague about where she’ll go after discharge. The family situation might not be as good as she said at first….”
Heart sinks. Groan. Oh dear….
I start… “OK. She needs proper assessment. Can we get someone from General Medicine to check her over? What about Geriatrics? Has she had spirometry from the respiratory team? Does she need a cardiologist? Social work will need to be involved for discharge postop. We need results of bloods, echo, any other tests from the last year or two. Need to clarify the home and family situation. We could get caught here with her stuck in hospital and not able to go anywhere. Hmmm. This is going to take a while to sort out. We’d better postpone her op. Hopefully we can get someone else to take her place on the list…… I just wish patients understood why they need to get a proper GP.”
I feel a failure. But the system of Medicare payments has failed our patient.
Modern medicine can perform extraordinary things. But the major challenge of healthcare in the 21st century is coordinating all the ‘simple’ tasks: managing the evaluation, treatment and coordination of multiple chronic conditions in the elderly. While patients and families must play a role, a single health professional needs to coordinate what is going on. And they should be paid for the value of that role. In Australia, the General Practitioner is the key to achieving this increasingly complex challenge. But Medicare does not support this role, and is increasingly undermining it.
Medicare is based on Fee-for Service payments. Services are defined on the Medicare Benefits Schedule. So a patient seeing a GP for a standard consultation can claim a standard rebate. For one-off patient problems, the Medicare system has worked well, and provides a baseline level of access to medical services. But patients have sets of inter-related problems. Bizarrely, Medicare does not reinforce the most important and valuable service that a GP can provide – that of co-ordinating and supervising all the various interventions by hospitals, clinics, specialists, allied health professionals and so on. The GP is not rewarded for providing a clear overview of what is going on, both FOR the patient, and ABOUT the patient (with their permission) to all those treating her/him.
Our health system is like a large collection of highly talented musicians all attempting to play a complex symphony. The GP should be the conductor of the healthcare orchestra, but they are not recognised (nor paid) for their crucial role of keeping everyone playing together. It is little wonder that the healthcare system often fails to function effectively or efficiently.
Some suggest that the whole Medicare Fee-for-Service structure should be completely reorganised and redesigned, with staff employed on salaries. It is entertaining to talk about what a ‘perfect’ system would be like. But it is also nice to dream of peace in the Middle East.
Attempts have been made to provide special payments for the long-term management of particular (complex) conditions such as diabetes. These initiatives are a step in the right direction, but their aims have been seen as cost-cutting, rather than quality-improvement. Regardless, these schemes are fundamentally flawed because the complexity is not so much the disease itself, but the multiple ‘simple’ problems that occur together in the same patient. Or as William Osler, the ‘Father of Modern Medicine’ said, “The most important thing to know is not the disease that the patient has, but the patient who has the disease”.
Every system has advantages and disadvantages. Our current Fee-for-Service based Medicare system works well for simple one-off consultations. It also has the advantage of being relatively easy to understand and administer. The improvement most needed for Medicare is to modify the existing MBS schedule to provide recognition and payment for the Service that patients need.
There needs to be a new Fee (i.e. an MBS Item number) for ‘Supervising and Coordinating care’ for an extended period of time, over and above the current system based on separate episodes of care.
What would be the features of such a Fee?: –
- The item would be paid to a single GP nominated by a patient (with the GPs agreement) to be their ‘Supervising Practitioner’ for an extended period (e.g. twelve months).
- The new item would pay for an initial ‘health care planning consultation’, and then ongoing supervision of the patient’s care for the twelve months. Assuming both patient and GP are happy, the role would then continue as long as the patient was ‘on the books’ of that GP.
- ‘Normal’ (one-off) consultations would continue as now, with the patient able to choose anyone to attend, but with a requirement that any service provided under Medicare would include providing a report to the ‘Supervising Practitioner’.
- The Supervising Practitioner would be responsible for maintaining the patients record (i.e. receiving and filing the above) and (with the patient’s consent) providing necessary information to other appropriate practitioners.
- The fee would be scaled for increasing clinical complexity. More complex patients may require a ‘Planning Consultation’ more frequently, such as three-monthly. There could also be a loading for rural, remote, frail elderly or ‘challenging’ patients.
- An ‘old-style’ GP practice, providing the valuable service of coordinating and supervising a patient’s long-term health care, may be able to derive (say) 20% of their income from this payment. A medical centre providing single-consultation without ongoing commitment would not gain the coordinating fee.
This plan would reinforce the strengths of Australia’s existing system of GPs being the foundation of the healthcare system. It rewards GPs who attract patients who are healthy and use self-maintenance to avoid medical consultations. It provides a framework to encourage GPs to move to underserviced areas where they will gain income for having patients ‘on their books’. It acts to shift the balance away from high-activity clinics focussed on short-term one-off consultations. It reinforces the status and importance of good patient-centred medical care. It might also encourage GPs to develop models of care less dependent on requiring the patient to physically attend the consultation. This may particularly help complex patients such as disabled, frail aged, or residential care patients.
The cost of this new item could be offset by removing some of the current ‘add-on’ programs that are costly to administer and do not necessarily or systematically encourage long-term supervision of care. It would also result in a reduction of waste because it would reduce duplication and provide a single place of reference about the patient’s health care. Treasury would be delighted to know that this particular part of the healthcare budget was fixed – each Australian could only generate one fee annually.
The system would enhance the status, rewards, and professional satisfaction for ‘traditional’ GPs as the foundation of the healthcare system. This may encourage more young doctors into general practice, by formalising a position of the ‘supervisory GP’; the GP’s involvement in high-stakes decision-making (such as planning complex surgery, or care at the end of life) would be established. This would clarify decision-making in hospitals considerably. Most importantly, it would improve long-term patient care.
This modification to Medicare maintains the positive aspects of the Fee For Service system, but rewards important long-term patient care that is not funded by the current system. It can be implemented as a modification of the current system without major redesign, but would nevertheless have major positive ramifications.
The Medicare system is imperfect. Some dream of major reform and wholesale redesign. Maybe that can happen in the long-term.
But in the meantime, who is your GP?
Associate Professor Ross Kerridge is an Anaesthetist and Perioperative Physician at John Hunter Hospital, a large teaching hospital in Newcastle. He is Associate professor at University of Newcastle and a member of AMA NSW State Council. These are his personal opinions.