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Evan Ackermann delivered the presentation at the 2014 Future of Medicare Conference. The Future of Medicare Conference was a timely event as the Abbott government debates a full over haul of the Australian healthcare system. This conference presented a chance for government representatives, regulators, health care providers in the public and private sector, educators and private investors to come together and debate the proposed changes to Medicare as well as discuss the best practice methods of implementing new measures and frameworks. For more information about the event, please visit: http://bit.ly/FutureofMedicare2014
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General Practice
Wiser health funding for better health at lower costs
Future of Medicare ConferenceSydney Harbour Marriott
Key Messages
• Medicare change won’t help if fundamental health governance problems, waste, poor health financing practices persist.
• General Practice is cheap, but not funded to be effective to meet current & future challenges
• A reinvestment in General Practice is required to make Australia’s health system more effective and efficient
• A medical home and GP population health management as the basis of restructuring GP services and funding can optimise value
THE VIEW FROM GENERAL PRACTICE
What are the key issues General Practice see contributing health funding problems
“The reality is that there isn’t a single point of leadership and accountability for health care in Australia*”
“….the structural flaws in governance and financing make it difficult to develop, fund and co-ordinate the primary care, subacute care and specialist care in the community that would be better for people’s care*”
…the failure to develop governance structures which promote the identification and resolution of problems according to their importance#.
Suboptimal Health Governance in Australia
• * Christine Bennett, ‘Are We There Yet? – A journey of health reform in Australia’ (Paper presented at the College of Medicine, Health Leadership Series 2013, The University of Notre Dame Australia, 18 March 2013)
• # Jeff RJ Richardson Steering without navigation equipment: the lamentable state of Australian health policy reform Australia and New Zealand Health Policy 2009, 6:27
Waste – in all shapes and sizes
Government
Federal Government
Technology savings not realised
– Pharmacy
– Surgical (cataract)
Non-Evidence based health system interventions
– Superclinics
– After hours telephone services
– ? PCEHR
State Government
Duplication / fragmentation
Poor Efficient services
(Hospital based primary care services)
Not closing redundant hospitals
Medical
Overdiagnosis & Overtreatment
– Disease definitions
– Poor clinical guidance (gestational diabetes)
– Cancer screening (prostate)
– Radiology (++)
– Protocol driven pathology
Healthcare variation in care
“Business of medicine”
• Corporate models of health driving expenditure
Copayments … the mixed evidence
Instituted broadly …
• blunt instrument for controlling costs
• Unfairly target poor
• specifically reduce beneficial preventive care practice
• Reduction in appropriate care not just unnecessary services
Targeted …
• Copayments may work where they are used to reduce demand for irrelevant, unnecessary, and inefficient health care
• Reinvestment of savings make the universal healthcare system more effective care
Copayments … practical applications
• To reduce radiology • To reduce pathology• To reduce use of inefficient activity in Public
hospitals• Lifestyle choices
– Smokers pay additional costs for vascular procedures
– Limits on IVF procedures– Some Cosmetic procedures
• To reduce inappropriate “health screening”• To reduce “futile care”
– The relentless pursuit of marginal improvement
• To reduce “low value” surgery• To optimise choice of medication
– eg prefer old diabetes drugs v new– “alternate” medicines
Figure 1 Productivity Commission – Report on Government Services DoHA (Department of Health and Ageing) , MBS, PIP, GPII, DGPP and DVA data collections;
Where is the
Problem?
Health Care is increasingly Hospital Centred
• Ambulances go straight to Hospital (even minor conditions)
• Increasing A&E Department use– ?health direct hotline– Incentivised by 4 hour rule
• Increasing Hospital Admission rates
• Inpatient Care– Palliative Care, End of life care, Aged
care, Multiple Morbidity
• Change in Discharge arrangements
• Funding Incentives – IHPA– Ambulatory care payments 2-6 times what
they pay through MBS and have lower claims criteria
*Australian Institute of Health and Welfare 2013. Australian hospital statistics 2011–12. Health services series no. 50. Cat. no. HSE 134. Canberra: AIHW# National Efficient Price Determination 2013-2014 Independent Hospital Pricing Authority Feb 2013
IHPA Payment Medicare for GP
Medical Consultations
Anaesthetics
Preanaesthetic assessment and evaluation - Specialist $291 $36 /$72
Preanaesthetic assessment and evaluation - Nurse $293
Obstetrics
Specialist Clinic $222 $36
Midwifery and Maternity $255
Alcohol and Other Drugs (Nurse) $156 $36
Sexual Health (Nurse / Allied Health) $185.48 $36
Minor Medical Procedures
Venesection (Hospital) $438 $62
Dematology - Cons + Biopsies (skin Cancer) $305 20.33
Wound Management (Nurse - excludes complex wound management) $245 $36
Comparing Hospital and GP payments for same or similar services
IPHA – Independent Hospital Pricing Authority
Comparing Hospital and GP payments for same or similar services
(a) Independent Evaluation of the ACT Nurse-led Walk-in Centre 30th June 2011b)Productivity Commission Report on Government Services Section E – Health
Table 11.A2 & 11A.10 2103
Nurse Walk in Centre - Canberra
Average cost per Service Av Cost for All GP Services
$196 (a) $49.58 (b)
Code Description Weight$ per patient service event
(IPHA)Allied Health
(MBS)
40.01 Aboriginal and Torres Strait Islander Health Clinic 0.0506 $249.61 $ 52.95
40.09 Physiotherapy 0.0376 $185.48 $ 52.95
40.18 Speech Pathology 0.0434 $214.09 $ 52.95
40.23 Nutrition/Dietetics 0.0261 $128.75 $ 52.95
40.25 Podiatry 0.0713 $351.72 $ 52.95
40.29 Psychology 0.0577 $284.63 $ 52.95
Comparing Hospital and Allied Health payments for same or similar services
IPHA – Independent Hospital Pricing Authority
The view from General Practice
The problems of medicare are not going to resolve if critical flaws (other than finance models) are not addressed
Similar funding arrangements to public sector
• have an honest cῸnversationabout health expenditure without political gaming
Determine what is an Australian version of a high performance health system and GP Role
MEDICARE AND GENERAL PRACTICEWhat's right and wrong now?
GENERAL PRACTICE HAS A BLENDED FUNDING MODEL
General Practices - Practice Incentive ProgrammePer Capita (SWPE)• Infrastructure eg (IT) / Nurses• Performance / Quality Incentive eg Diabetes Cx Screens• Services population ie ATSI
General Practices and General Practitioners - Fee for Service • Medicare Benefits• DVA• Workcover• Private
General Practitioners• Practice Incentive Programme
• Skills (Rural -Anaesthetics, obstetrics, Surgery)• Aged care access
• Other• Rural Incentive• Service Incentive Payments
Medicare -Australian Government real expenditure on GPs (2012-2013 dollars) per person
*Fee for Service = $286 per year for every woman , transgender , man, and child
$0.78 per day
* Productivity Commission – Report on Government Service DoHA (Department of Health and Ageing) , MBS, PIP, GPII, DGPP and DVA data collections; Chapter 11 Primary and Community Care table 11A,2
GP Costs
Medicare -Australian Government real expenditure on GPs (2012-2013 dollars) per person
*Add Radiology= $58.60 per year for every woman , transgender , man, and child
$0.17 per day
* Productivity Commission – Report on Government Service table 11A.65
GP Costs
Fees $0.78
Medicare -Australian Government real expenditure on GPs (2012-2013 dollars) per person
*Add Pathology= $58.60 per year for every woman , transgender , man, and child
$0.16 per day
* Productivity Commission – Report on Government Service table 11A.63
GP Costs
Fees $0.78
Radiology $0.17
Medicare -Australian Government real expenditure on GPs (2012-2013 dollars) per person
Total GP Costs per day per person to medicare
$1.13 per day
* Productivity Commission – Report on Government Service table 11A.63
GP Costs
Fees $0.78
Radiology $0.17
Pathology $0.16
How cheap is GP Care ...
Daily GP Costs Packet of Chips
$1.13 per day $1.45 per pkt
“Largely delivered by private practitioners, …. the many community based services that could help keep people well and out of hospital or provide a better and more cost effective care in a non-hospital environment are underdeveloped, underfunded and poorly co-ordinated.”*
We argue strongly that strengthened primary health care services in the community should be the ‘first contact’ for providing care for most health needs of Australian people.. This builds upon the vital role of general practice.
How effective is General Practice for today’s health care problems?
* Christine Bennett, ‘Are We There Yet? – A journey of health reform in Australia’ (Paper presented at the College of Medicine, Health Leadership Series 2013, The University of Notre Dame Australia, 18 March 2013)
THE FUTURE FOR GENERAL PRACTICE
If we want a high performance health system, what roles and functions of General Practice should be Medicare funded?
The fundamental paradox of primary care:
‘…a paradoxical situation: the tension between the relative weakness and unattractiveness of this level care versus the intention to assign critical strategic functions to it.’
From: Primary Care In the Driver’s Seat? Saltman, Rico and Boerma (eds) 2006
Palliative Care
Complex Patient Care
Active Chronic Disease Management
Chronic Disease – Self Care
At high risk for Chronic Disease
Well Population
GENERAL PRACTICE HAS A BLENDED FUNDING MODEL
General Practices - Practice Incentive Programme
CHANGE
General Practices and General Practitioners - Fee for Service
• Medicare Benefits
• DVA
• MAINTAIN
General Practitioners
• CHANGE
Practice Incentive Programme for General Practices
New Rationale - : To encourage General Practices to organise the infrastructure for appropriate and comprehensive primary care delivery that adds value to their local communities and the health sector
Traditional GP Practice
“Niche” GP Practice
Corporate GP Practice
“Models” of General Practice are changing
1Implement the Medical Home
Registration with 1 Doctor & 1 Practice
Delineates site/role of primary care
Patient Registration will facilitate population Health activities
*
Delineate new roles for General Practices –then support them
New General Practice Characteristics
Advanced Multidisciplinary health care teams
Comprehensiveness of services to match local need
Clinical governance
Population management (Hospital avoidance)
Health Service integration (?financed by states)
Quality Management
Key Messages
• Medicare change won’t help if fundamental health governance problems, waste, poor health financing practices persist.
• General Practice is cheap, but not funded to be effective to meet current & future challenges
• A reinvestment in General Practice is required to make Australia’s health system more effective and efficient
• A medical home and GP population health management as the basis of restructuring GP services and funding can optimise value
