The Federal Government’s new Strengthening Medicare Taskforce met for the first time last week, and released a communiqué outlining its key priorities and overall approach, as Croakey reported together with some insights shared by taskforce member Professor Stephen Duckett.
This week Croakey editor Jennifer Doggett asked a number of health groups and experts who are not represented on the Taskforce for their advice to the new group on how to develop and implement a reform agenda.
Below are responses from Adjunct Associate Professor Lesley Russell, a Croakey columnist and health policy analyst from the Menzies Centre for Health Policy at the University of Sydney; Jasmine Davis, President of the Australian Medical Students Association; Scott Willis, National President of the Australian Physiotherapy Association; and Danny Vadasz, CEO, of the Health Issues Centre.
In addition, Mark Burdack, CEO of Rural and Remote Medical Services Ltd, highlights the urgency of the rural workforce crisis and calls on the Taskforce to ensure practices in rural areas remain open while developing a longer term workforce agenda.
Three mental health advocates – Dr Sebastian Rosenberg, from the Brain and Mind Institute, advocate and consultant Simon Katterl, and Gill Callister, CEO of Mind Australia – also call for mental health to be a high priority if the Taskforce is to improve the current inequitable, fragmented and inefficient approach to the provision of mental health services in the community.
Jennifer Doggett writes:
Overall, stakeholders were supportive of the five focus areas identified by the Taskforce, with Associate Professor Lesley Russell noting that it was a “very positive sign (and indeed a relief) to see the encompassing nature of the five focus areas”.
In particular Russell welcomed the focus on a multidisciplinary workforce, new models of care (and presumably financing) to address the community-based care of those with chronic and complex conditions, and the emphasis on inclusivity and addressing disadvantage.
The Australian Medical Students Association (AMSA) also welcomed the five focus areas, said President Jasmine Davis, who noted that AMSA was looking closely at the outcomes of focus area one: building a strong and vibrant primary healthcare workforce.
Australian Physiotherapy Association (APA) President Scott Willis added the APA’s support for the direction proposed thorough the five focus areas:
We particularly welcome the focus on workforce in developing a training pipeline as key reform element. We urgently need to address critical workforce shortages in primary care by leveraging the skills of the entire health workforce – valuing skills must be core to the response with solutions beyond general practice workforce planning.”
The inverse care law
Danny Vadasz, CEO of the Health Issues Centre, expressed concern that the focus areas do not directly address one of the key failures of primary care, “the asymmetric access to healthcare experienced by those disadvantaged by social, economic and environmental determinants”.
He said that while it is laudable to highlight the special needs of “older Australians and those with complex and chronic conditions”, these are by no means the only populations, or condition specific groups that need “new models of care and stronger relationships”.
An aspiration for universal care that is ‘inclusive and reduces disadvantage’ is diminished to no more than virtue signalling if it isn’t accompanied by specific, enabling actions. Training and development will build workforce capacity, harnessing skills across a range of disciplines will better enable multidisciplinary care, new models of care will help better serve differentiated need and digital technology will open the door to modernity but none of these will automatically or necessarily herald a path to inclusiveness and equity for those who are already disadvantaged.
In fact they could exacerbate existing inequity. Relying on implicit intention is not enough. We need an overarching, overt commitment that all these worthy and essential investments into primary health reform will be scrutinised through a lens that ensures no one gets left behind.”
Vadasz suggests that an overarching principle for the Taskforce should be:
That every recommendation of the Taskforce will be subject to a consideration of its relevance to and impact on those consumers who are currently disadvantaged in receiving equitable healthcare.”
This recommendatiom is based on his belief that if you raise the benchmark of care quality for those who are most vulnerable, then you effectively raise the overall standard of care for the whole community. Therefore the positive impact of reform on vulnerable consumers should be the key performance indicator that defines success.
Vadasz added that we also need to ensure that while we are “harnessing the power of technology”, those who lack digital access or literacy do not perversely experience further barriers to receiving good care.
Other identified gaps
Russell identified several key issues she felt were important enough to warrant a particular focus from the Taskforce, including mental health, access to primary care for people in residential care, and services for rural, remote and medically under-served communities.
Willis said that the APA would also like to see a commitment to a national health workforce plan encompassing allied health alongside incentives to drive strong skills growth as well as policies to advance team-based care. He also stressed the importance of strengthening data and systems to undertake needs analysis of the health workforce.
Willis also noted that previous primary health care reforms had failed to address key issues of affordability and access to services and suggested that this would require looking at new models of service delivery beyond the traditional specialist frameworks.
It is time for some real outcomes and a different approach so that reform better aligns to care needs. Efficiencies can be found through expanding workforce roles and scopes of practice including by allowing patients to be treated by physiotherapists in the primary care setting.”
Davis said that AMSA was disappointed to see no particular commitment for recruitment and retention of rural and regional General Practitioners or the Aboriginal and Torres Strait Islander workforce. Along with Russell, Davis also stressed the need for any proposed reforms to be properly evaluated:
We would like to see commitment that any new programs or initiatives will undergo rigorous evaluation and monitoring to ensure that we do not have a situation such as that with the Bonded Medical Program where we are unable to adequately evaluate its effectiveness due to a failure to adequately evaluate and collect data on the program.”
First steps and practical strategies
Prioritising areas where efficiencies can be easily found, such as lifting structural barriers impacting on the patient pathway, should be the initial priority for the Taskforce, according to Willis.
Connecting patients to the most appropriate and cost-effective pathway is an immediate action that should be prioritised without delay. The patient pathway can be improved by lifting the structural barriers to reform.”
In particular, the APA wants the Taskforce to look at the following two simple solutions which Willis says will streamline the patient journey in primary care:
- Changing the MBS requirement for GP referrals to allow physiotherapists to directly refer to the most suitable medical practitioner.
- Allowing physiotherapists to refer for musculoskeletal imaging through the expansion of imaging items of the MBS.
These changes will reduce take pressure off busy GPs, improve access to specialist care and reduce MBS costs, according to Willis.
Physiotherapists often need to refer to a GP, even when they have assessed that a medical specialist is the most suitable health professional. The right for physiotherapists to refer to medical specialists would improve the patient journey, result in cost efficiencies, reducing GP visits by around 737,000 per year and ensure better use the existing workforce.”
Russell stressed the importance of clarity of purpose, in particular in relation to distinguishing between primary care or primary healthcare, given that these have different aims and require different resources (specifically, a focus on social determinants of health and social services for primary healthcare).
Russell also highlighted the need for a better understanding of the current business models for general practice and primary care and the type of workplace and remuneration structures that healthcare professionals want. She advised the Taskforce to:
Be very open to the range of health care professionals needed – for example, consider the inclusion of geriatricians, paediatricians, healthcare coordinators. And ensure that the system structure/s and funding provide for all to work to full scope of practice with appropriate access to Medicare.
Regard fee-for-service as not fit for purpose in the delivery of Medicare services, especially for those patients with chronic and complex conditions.”
Russell also suggested that the Taskforce investigate mechanisms for providing primary care services when and where they are needed, for example, after hours, in schools, aged care facilities and workplaces.
On a practical note, Russell pointed out that there are existing examples of healthcare facilities and professionals providing innovative primary care in their local areas. She suggested using these experts to identify enablers and barriers and help deliver and implement the proposed changes.
She also stressed the need to allow reasonable timeframes to implement the changes and to provide clear communications to all stakeholders (healthcare professionals and consumers) about these changes, including the evidence and rationales that underpin them.
Davis nominated a number of specific issues as important priorities for AMSA: These include:
- the promotion of General Practice as a worthwhile career option for medical students and junior doctors to ensure the sustainability of those coming through the pipeline;
- consultation with medical students and doctors in training to ensure that changes are appropriate for those undergoing training or thinking about undergoing general practice training;
- workforce planning in relation to general practice underpinned by data and evidence, as recommended by the National Medical Workforce Strategy (2021-2031)
- a funding allocation system which is informed by the Inquiry into the Provision of General Practitioner and Related Primary Health Services to Outer Metropolitan, Rural, and Regional Australians (2021-22).
Lessons from the past
All the experts consulted by Croakey advised Taskforce members to be open to doing things differently and to consider flexible and evidence-based approaches to meeting diverse community needs.
“Doing the same thing under a different name will not deliver improved health outcomes,” warned Russell. She stressed the need to resist loud medical voices pushing their agenda at the expense of other healthcare professionals, patients and carers.
Russell also warned of the dangers of trying to impose a “one-size-fits-all approach” and suggested that Taskforce members “mine the archives” and examine what has been learned from the many past pilot programs rather then re-inventing the wheel.
Willis urged the Taskforce to “just start implementing” rather than waiting to develop another reform plan.
It is critical that we move beyond this point. The former Morrison Government left us in a phase of perpetual planning with five key reform pieces drafted but without any progress towards implementation. To keep pace with increasing demand, the implementation work needs to start now. However, we lack the funding commitment and systems to guide it.”
Barriers and enablers
Willis nominated “a continued narrow policy lens that deems essential non-medical care as ‘ancillary’” as the key barrier to reform.
There is strong evidence for integrated care models that include allied health services, yet successive health budgets have continued to deliver no or insignificant change from conventional primary care. Have the courage to properly fund primary care to support greater levels of integration to meet the needs of a changing population.”
Russell identified “ongoing turf fights between medical and other health professional organisations” as the major barrier to making progress and also mentioned some key enablers, including:
- Adequate and sustained resourcing
- A transparent approach to informing all stakeholders about the reform process
- Consideration of the intersections of primary care with other aspects of the healthcare system.
- Strong and brave leadership and ongoing commitment from the Albanese Government (ideally with full parliamentary support).
Davis highlighted a need to connect Medicare reform to other health system processes, and identified the National Medical Workforce Strategy, Stronger Rural Health Strategy and Aboriginal and Torres Strait Islander strategies as key relevant initiatives for the Taskforce to take into account.
Davis also stressed the importance of achieving buy-in from all stakeholders, along with coordination by the Department to ensure that this relatively small amount of funding has the highest possible impact. “The ability for stakeholders who are not represented in the Taskforce to submit proposals to the Taskforce would be welcome,” she added.
Rural and remote concerns
Mark Burdack writes:
Rural and remote communities have an expectation of universal access to healthcare regardless of where they live. But this isn’t happening.
The only way to strengthen Medicare for rural and remote people is to deal with the elephant in the room – our medical workforce policies are producing the wrong doctors, for the wrong places and at the wrong time. That is because our medical workforce policies are industry-centred, not people-centred.
Without doctors and health professionals accessible to communities Medicare doesn’t work. This is the reality facing rural, remote and Aboriginal people across our country.
No doctor equals no healthcare equals no Medicare rebate. No doctor equals no prescription equals no PBS rebate. The list goes on.
Medicare and the PBS has been slowly eroded over many years as a result of industry-centric workforce policies that ignore the type of doctors and system rural communities need to remain healthy.
The National Rural Health Alliance has calculated that there is a shortfall of around $4 billion annually in Medicare and other funding going to rural and remote areas due to a lack of access to GPs and health services.
This is money that Treasury expects to spend on rural and remote health every year. Rather than pocketing this as a budget saving, we believe that this money should be returned directly to rural and remote communities as block funding to support ‘continuity of care’.
Continuity of practitioner vs continuity of care
All of our primary health models have been built around the ‘continuity of practitioner’ (industry-centric). Historically, this meant that if the local GP left town the practice would close and there would be a snowflake’s chance in hell of ever getting it back due to the cost of starting up a new practice.
The RARMS Program was designed by rural and remote people around the principle of ‘continuity of care’ (person-centric). We recognised that continuity of care is about more than a GP, and building a health system on the availability of a rural GP was a recipe for disaster.
The focus on ‘continuity of care’ is why RARMS, and other similar community health organisations around Australia, have been able to keep services going.
We recognised that there is a whole team of people who work in general practices, including reception staff, practice managers, nurses, allied health staff and Aboriginal Health Workers, who play a key role in the care of patients. We built a model for rural and remote Australians that meant that practices could continue to deliver high quality care, even if there was a vacancy in the GP position.
We believe that a high priority for the Taskforce is to invest in ‘continuity of care’ in rural areas. This requires that some of that $4 billion that the government saves on Medicare and the PBS etc to be returned as block funding for community-led and operated rural health care centres right across rural Australia.
Extending Medicare eligibility
We need eligibility for Medicare rebates to be extended to nurses, allied health, mental health and other professionals on condition that they work with a community-led rural health care centre consistent with their scope of practice. Strengthening Medicare means strengthening community-led local health service, not facilitating artificial competition where none exists.
We need rural people to be in the driving seat. Every year millions of dollars of rural health money are wasted on administrative costs. This has done nothing to arrest the decline of healthcare and workforce in rural and remote towns. Its time for rural money to go to rural people.
More than 70 percent of our nation’s export wealth comes from rural and regional areas. Without the toil and innovation of rural and remote people our economy would have no buffer against global economic downturns. All Australians – rural and urban – benefit from keeping rural and remote communities sustainable.
Rural and remote Australia is the home of the oldest living civilisation on earth. From these First Nations we must learn from our past mistakes. We cannot add to the sorry story of our nation by continuing to treat one group of people in this country as lesser than others.
My main message to the Taskforce is to first keep practices going and then get on and do your job and fix the bloody workforce crisis.
Focus on reform, rather than remuneration
Sebastian Rosenberg writes:
Perhaps no area of government activity attracts as much unalloyed public support as Medicare. The great majority of Australian support universal public health insurance.
This elevates the role of the Labor Government’s Strengthening Medicare Taskforce – everyone has a stake in Medicare.
An important first job for the Taskforce to consider the level of its ambition. A minimalist approach will see the Taskforce focus on the endlessly fascinating topic of wages – specifically whether general practitioners, allied and other health professionals who all generally operate as private, for-profit businesses are adequately remunerated by public funding through Medicare rebates.
All the key industrial groups have seats at the table (though not, it should be said, mental health professionals), ready to argue the wage case. Several have already issued public statements suggesting that increasing the Medicare rebates is “at the heart” of necessary reforms. The propensity of all groups to focus on remuneration rather than reform is a key barrier the Taskforce must overcome if it is to make meaningful impact.
A more ambitious agenda
A more ambitious agenda which could see the Taskforce look beyond funding to consider the five key areas identified by the Government already:
- Improved patient access to General Practice, including after-hours GP access
- Improved patient access to GP-led multidisciplinary team care, including nursing and allied health
- Greater patient affordability
- Better management of ongoing health conditions including chronic conditions
- Decreased pressure on hospitals.
As a starting point, it is worth considering exactly what is meant by ‘primary care’. It seems that the current definition focuses very much on general practice, nursing and allied health. This might be derived from the 2009 National Health and Hospital Reform Commission report, which rather excised the role of specialists in the delivery of primary care.
From a mental health perspective, there are lots of issues here. But the overarching one concerns the workforce. Not just the numbers which are obviously critical, but also the design. The recent 2020-21 National Survey of Mental Health and Wellbeing found that 47 percent of the Australian population with a mental illness requiring professional assistance received care. So the majority of Australians needing mental health care are still missing out.
In fact, the Taskforce could do worse than to focus on the key workforce design question facing mental health: who needs what help, from whom, with what expected outcome and what happens if the consumer gets better or worse?
The way our mental health system is currently configured, the answer to this question is far from clear. It is difficult for consumers to discern the difference between seeing their GP, a registered psychologist, a clinical psychologist, a psychiatrist, a social worker, an occupational therapist or even a mental health nurse.
And while many consumers may wish to in fact see a peer worker, these remain in very short supply. In the same way the term ‘mental health’ is an unhelpful catch-all, the mental health workforce is now a blancmange where the different but complementary skills of various professions have lost their meaning.
Establishing multi-disciplinary models
So rather than argue just about remuneration, mental health needs to consider issues like role delineation, scope of practice and multidisciplinary teamwork. The current Better Access Program was never designed for long term interventions for people with complex problems. Especially for these people, just going to see the same doctor or psychologist over and over again may not yield positive results.
As the Productivity Commission said in relation to the Better Access Program, one size does not fit all. A young person with an eating disorder, for example, might need a mixture of care from a range of disciplines, as well as peer support. Medicare’s individualised fee-for-service treatment payment system is a disincentive to this kind of organised teamwork, including the engagement of the specialist care required to respond to this kind of complexity.
I note here too New Zealand’s TePou organisation, set up specifically to train health professionals to work together. Australian efforts to establish multidisciplinary models in mental health has been spasmodic at best. The Mental Health Nurse Incentive Program, Partners in Recovery and Personal Helpers and Mentors are three short lived and relatively small scale examples, now defunct.
Targeting access in non-urban settings
This is perhaps especially true in non-urban settings. The Medicare Taskforce could respond to the challenge enunciated by the Orange Declaration, to recognise that rural mental health needs fundamentally different services, models and funding. This recognition would fit with recommendations made by the Productivity Commission suggesting that the future of mental health planning, funding and service delivery should be regional, rather than centrally controlled.
While Health and Aged Care Minister Mark Butler has expressed “terror” in relation to a shortfall of GPs, until the design of contemporary primary care is finalised, the ‘right’ number of all professionals is surely hard to determine. At the moment in mental health, one of the key issues is the unevenness of distribution of the workforce, which tends to aggregate in the more well-heeled suburbs of our larger towns and cities. Recent modelling has demonstrated that simply providing ‘more GPs’ may not be the most efficient way to address service gaps.
This is also where newer telehealth and information technology-driven services can play a much more prominent role as part of a better coordinated primary care system.
Taking pressure off hospitals
In principle the Taskforce is charged with considering how community and primary care services can reduce the pressure on hospitals. Hospital avoidance is important in most areas of health, but not mental health.
An unhelpful cleavage has arisen, with Federally-funded services typically aimed at people with low to moderate mental health needs, while state-based services are difficult to access unless you are extremely unwell. Two separate funding streams for two separate client groups. There is little if any continuity of care.
I do not think Australian data currently permits us to understand how many Medicare mental health clients visit hospital (or avoid it). We lack the necessary data linkage to build this picture. Similarly, we cannot determine easily the extent to which pathways into mental health care predominantly come from primary care versus patients arriving from emergency departments (ED).
The Taskforce must build this fuller picture of how our system operates, the links and the gaps and then identify opportunities to create new links, regardless of the source of mental health service funding.
And in addition to this kind of data problem, is the service problem. Both Federal and Victorian Governments are now trying to build community mental health clinics, in recognition of the dearth of service options between the GP and the ED. This is welcome but late.
Mental health lacks secondary care, where specialists can provide support to primary care to address increasing levels of need outside the hospital. A key area for the Taskforce could be to design the features of this secondary mental health care, including both medical and psychosocial elements. As stated, access to any mental health care remains a key challenge. But our current approach is disorganised and ramshackle. Health professionals are not supported to provide good care.
Quality and accountability
This last point moves us away from issues of access and equity and into the unexplored territory of quality. Medicare funding for GP mental health care was $316.8m in 2019-20, with a large chunk of that derived from the creation of the mental health plans that act as flag fall for sessions of psychological care.
But do these plans do much else? Very few plans are reviewed by the GPs, after the psychologist has finished.
My GP friends tell me this does not mean patients are not monitored. This may be true. But in the same way we know nothing about the outcomes of $650m of Medicare spending on psychology and allied health, and $389m on psychiatry, the Taskforce must address the lack of outcomes and accountability.
The Taskforce and the new Government have a significant opportunity to reboot Australia’s mental health system. The eight mental health agreements struck between the Federal and state/territory governments represent perpetuation of the same fragmented and piecemeal approach to planning that has been criticised in report after inquiry after commission. Enough.
Addressing physical health needs
But I am realistic enough not to expect miracles. The Taskforce should start by identifying a small number of practical areas of joint activity between state and federally funded services. The life expectancy of people with mental illness is akin to Australia’s Indigenous peoples. They die not of mental illness but of untreated physical conditions and comorbidities.
A natural place for the Taskforce to focus would be on that relatively modest but readily identifiable group of about 467,000 Australians who attend hospital inpatient services for mental healthcare. Tracking them back to the community and ensuring their physical health needs were met would not only be good care, it may well contribute to forestalling future admission to hospital.
The potential impact of an ambitious Taskforce working for primary mental healthcare reform is significant. Its work is hampered through lack of mental health specific expertise in its membership. But this is not fatal and can be surmounted.
A lack of ambition on the other hand, would be lethal.
Lived experience matters
Simon Katterl writes:
I’m concerned about the lack of a lived experience perspective on the Taskforce. There is one person from the Consumers Health Forum who apparently has to represent every single consumer, of every race, gender, background and geographic location, accessing every single health service.
If consumers are to have a genuine influence over the Taskforce outcomes, the membership needs to be expanded to include more people with lived experience.
I welcome the Taskforce’s focus on achieving “patient-centred and easy” access to care but this will be almost impossible to achieve when patients are largely left out of the process.
I’m also concerned about the lack of focus on mental health. Part of the reason we don’t have a mental health representative on the Taskforce is that we don’t yet have a mental health consumer peak. This has been planned for 10 years now but has not gone ahead. Hopefully the current Government will action this.
I am also concerned that there is nothing prioritising mental health in the first communique from the Taskforce. This is concerning. We are still waiting for the implementation of the recommendations from the Productivity Commission report, it’s not clear whether the Taskforce is going to have a role in this.
I would like to suggest including a focus on human rights and inequity in the Taskforce’s priorities, particularly in relation to the health of Aboriginal and Torres Strait Islander people.
Bringing a human rights focus to this issue would help address many of the gaps and inequities in our current system, including culturally safe services for First Nations people, accessible and equitable care for people with disabilities, and gender affirming care for trans and gender diverse folk.
A human rights framework would help improve health at both the individual and systems level.
Creative solutions needed
Gill Callister writes:
Mind welcomes the announcement of the new Medicare Taskforce and its terms of reference, particularly the emphasis on universal healthcare for all and reducing disadvantage.
We know that people with serious mental health issues have significantly lower life expectancies than the general public. A meta-analysis of studies worldwide has estimated that people with mental illnesses have a mortality rate 2.2 times that of people without, and between 1.4 and 32 years of potential lost life. This reduction in life expectancy is well established by numerous studies and reviews.
This is not just related to mental health issues but very often for the co-occurring physical health issues that disproportionately affect this population. We know that these groups have frequent and often unplanned visits to Emergency Departments and are over represented in the groups that experience very long stays in hospital.
They are also less likely to have a regular GP to support them to manage a range of complex health needs and are sensitive to out of pocket costs for healthcare.
Despite not insignificant amounts of spending through mental health programs and the NDIS, we still have a very fractured, uncoordinated system and these groups frequently fall through the gaps. In a number of states, for example, there are large numbers of people with psychosocial disability stuck in hospital because, in essence, there is no clarity between state and territory and Commonwealth governments as to whether they should be supported through the NDIS or through state funded rehabilitation programs.
In the interim, people are unnecessarily stuck in the acute care sector, which both inhibits recovery and is expensive. There is a very human cost to some of the inefficiencies and disagreements that governments have over funding.
There is also a lot more that the community-based mental health sector – focused on rehabilitation, recovery and helping people rebuild their lives – could do in this space. We know our programs are effective in preventing unplanned visits to hospital.
Our workforce is skilled, more accessible and, on average, more cost effective than the clinical workforce and we partner with the clinical health sector to support people’s wellbeing and recovery.
I would urge the Taskforce to think creatively about how we solve problems for those who are really disadvantaged through the current mechanisms of funding healthcare, and to see that this sector with 40 plus years of experience stands ready and willing to help.
Both the NDIS and some of the very fractured ways of commissioning services through the PHNs have not lead to sufficient systemic change to shift outcomes for people living with mental ill health. It’s time they did.
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