The Medicare Review: how will its aspirations be achieved?

Feb 10, 2023
Directly below shot of medical team joining jigsaw pieces in huddle against white background

The Medicare Review contains welcome aspirations, but the instruments to achieve them are poorly delineated.

An early statement in the Medicare Review report is challengeable. “Most Australians enjoy ready access to quality Primary Care services and with that good health outcomes”.

That is certainly not true for the 33% of Australians who live in rural and remote communities. Nor for those living in socio-economically deprived areas of our cities. We are one of the fattest nations on earth and though we are living longer, 50% of us by the age 50 suffer from a preventable chronic disease interfering with the quality of life. Far too many of us are burdened with a number of chronic illnesses. Our nation could be and should be a lot healthier than it is.

This is a report about strengthening Medicare but actually it only focuses on Primary Care. Medicare involves more than that. Ignored are the problems our current arrangements produce for the integration of public hospital care (a part of Medicare) with Primary, community delivered care. This is primarily generated by funding complexities and one would have hoped the reviewers would have called for this to be corrected as a matter of urgency. The timing for action on this is right with Labor and Liberal Premiers recognising the clinically devastating inefficiencies associated with not having a single funder for all of Medicare, a reality that makes person-centred care, repeatedly touted in the review as essential, so difficult to achieve.

While many of the changes the reviewers suggest are appropriate, in many cases crucial, to this reader there is a lack of a sense of urgency the situation deserves. The review complements a ten year plan and emphasises that “It is important that reforms aren’t rushed and are introduced logically and incrementally”. But today Medicare is drowning and is no longer fit for purpose, we need life-savers to pull it out of the water before it collapses completely.

Most of the suggested changes in the review are obviously appropriate and in many cases have been discussed (and recognised as important) for years e.g. “multidisciplinary care”. National Cabinet will meet in two months to respond to the review. However those of us who have been advocating for structural reform to our health care system for many years are certain that significant changes will only occur when driven by a powerful government instrumentality, created by a partnership between State and Federal governments and thus politically acceptable to all. Such a body would report to a National Cabinet and the Australian people.

Such an instrument, an “Australian Health Care Reform Commission” was first touted by the Whitlam government but no government since. I do not believe evidence based changes recommended in the current review can be coordinated and implemented without such an agency driving reforms.

We have a major workforce problem in delivering the Primary Health Care system we want, well described in this review. We no longer have sufficient numbers of doctors working as General Practitioners to meet demand made worse by maldistribution of those available. The median age of GP’s is about 50. Only 14% of medical graduates are contemplating a career in Primary Care. By the end of the century we will have 50,000 fewer GPs than we need. The situation is no better for nursing with a likely end of decade shortage of at least 150,000.

Given these work force issues I was disappointed that the Medicare review did not recommend the re-establishment of Health Work Force Australia (HWA), a vital instrumentality abolished by the previous Federal government.

In these inflationary times, GPs, so many of whom were financially disadvantaged by the need to vaccinate and care for patients with Covid-19, simply can’t afford to run their practices on the money available from “Bulk Billing”, rates of which are plummeting. While certainly not the only factor, remuneration is a major issue in career decision making for young doctors.

Perhaps the most important initiative emphasised in the current review, is encapsulated in the reviewers’ belief that “We need systems and funding (my emphasis) that supports comprehensive continuity of care delivered by well connected teams working together to address people’s health needs. Multidisciplinary care teams can increase the ease of engaging with the system, deliver better health outcomes and help people to better engage with and manage their own health”. Amen to that!

The “well connected” concept in the above is all important. Perhaps the biggest complaint of patients with Chronic and Complex diseases concerns the lack of information and geographic integration of the different professionals they need to see.

Regular readers of P&I will know that for years I have discussed that “well connected” requires “team medicine” to be delivered from the one location that constitutes one’s “Medical Home”. Therein the multidisciplinary talents available from nurse managers, allied health professionals, cases managers, community nurses etc, allow for a full utilisation of different skills (a major aspiration of the reviewers). For a number of years Universities have been preparing clinical students for a career in “Integrated Medicine” but career opportunities to practice this way have been few.

Much is made in the Medicare review of the concept of voluntary “enrolment” in a practice to encourage continuity of care, such a crucial concept for disease prevention and optimal management. Enrolling in a medical home, as described, is the best application of this initiative. The “Holy Grail” for optimal care of an individual and their families in terms of both prevention and disease management is the Medical Home model funded by Medicare.

The one missing yet crucial link in the above comprehensive plan is timely and affordable access to specialists. Some Medical Home models in other countries feature regular visits to the “home” of relevant specialists. In our current situation however as we discuss comprehensive accessible care, so important, though not mentioned in the review, is funding for the resurrection of Specialist out-patient clinics in our public hospitals, an initiative Labor promised to implement before the 2019 election. That I believe is an absolutely crucial issue for any discussion of “Strengthening Medicare”.

Hospitals and hospital care do not get enough attention in the review. Yes, there is emphasis on improving after hours access to GPs and the establishment of acute care centres to handle “minor emergencies” but the major problem crippling our hospitals is the tsunami of sick, often chronically ill medical patients many of whom present huge problems in terms of safe discharge. I mention this here because the evidence is clear that hundreds of thousands of such admission would be avoidable if timely care was provided in the community setting by clinical teams that know and follow the patient’s wellbeing. This alone could pay for the costs of the clinical teams we want Medicare to fund.

I would end this exploration of the review with a plea to government to establish the Reform Commission described above and fund it to run trials across Australia of the Medical Home model for delivering Primary Care to assess its suitability for modern day Australia with its current and worsening crisis in providing equitable quality care. Please government, recognise the need to integrate hospital care into any plans to “Strengthen Medicare”.

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