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Advice for the Strengthening Medicare Taskforce from health groups and experts

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 ru