Pretty much everyone with an interest in improving primary care agrees that instituting some model of the patient centred medical home in Australia is a good idea.
It was thus not surprising to see widespread support, in concept, for the Government’s announcement of the trial of Health Care Homes as part of the Healthier Medicare initiative.
In announcing the Health Care Home trials, the government said it would be establishing a Health Care Home Implementation Advisory Group “to oversee the design, implementation and evaluation of the trials ahead of the national rollout” So far, the composition of this group is not known and details about the trials are thin on the ground.
In a post last week, Tim Senior, GP and author of Croakey’s Wonky Health series, reiterated his support for the patient centred medical home but cautioned that the model of funding would determine access, and was therefore very important. In in order to be effective in improving outcomes for people with chronic disease, the Health Care Home will need to be available to everyone who needs it.
While the official announcement did not mention a role for private health insurers in the trials, “Maximis(ing) the effectiveness of private health insurance investment in the management of chronic conditions” was certainly a focus of the Primary Health Care Advisory Group‘s report, on which the trials are to be based. Private health insurers have also flagged their interest in being more involved in chronic disease management in primary care, including booking a slot at to address the upcoming Primary Health Care Research Conference.
As we await more detail about the Health Care Home trials, Croakey sought advice from health policy experts and put some questions to the Minister for Health’s office.
Emeritus Professor Stephen Leeder
Co-ordinating primary care: an informed debate about the role of Private Health Insurers would be welcome
A recent review of ways that better care can be provided for Australians with chronic and complex illnesses has confronted a serious lack of connection among hospital and community services. It has proposed different ways of paying for care that place general practitioners (GPs) at the centre of care.
GPs will be paid for the patient they care for rather than the items of service they provide or arrange. This proposal was endorsed by the prime minister when he announced recently a partial reprieve to the 2014 federal budget cuts to health care.
Australia has experimented with co-ordinated care of this sort twice before. The results were disappointing. Management was poor and expected cost reductions were not achieved. Lessons have been learned and are reflected in the new proposals.
McKinsey and Company, a consultancy, has had extensive experience assisting with similar programs in the US and Europe. From that experience we know that IT connections among care providers and patients is a great help.
Further, If the system of care is closed, by which is meant that one and only one source of finance is in place, things go more smoothly. If incentives are included for quality care (measured using IT and judged by patient satisfaction and avoiding crises that lead to expensive hospital admission) and sanctions operate for care that is below standard, things go even better.
The proposals for integrated care for patients with chronic problems in Australia include suggestions that private health insurers might participate. Details about the way in which this would operate are scarce.
Other countries have experience of using private health insurers in this way that is relevant to Australia, so an informed debate would be welcome about what they might do here.
In the US where private insurers have responsibility for the total health care of members, such as is provided to millions of American by the massive Kaiser Permanente (KP) and similar systems, evaluation data show good results. Of course, to get the results you need to be a member of KP.
In Australia where concern for equitable access to care irrespective of ability to pay at the time of care and private insurance status is the fundamental principle of Medicare, there would need to be much discussion to hammer out details.
Dr Lesley Russell
Much work to be done to ensure accurate targeting and equity of access
As with all such policy announcements, the devil for the new Health Care Homes initiative is in the details, and there are very few details here, especially given the short time frames.
Are there realistic expectations that there will be agreements about the appropriate model or models for Health Care Homes, where the pilots will be implemented and how the target populations will be selected, and that sufficient information will be available for impact and reporting by 2018 when it is proposed that a longer-term public hospital funding agreement is to be developed, or even by 2020 when the current agreement concludes?
A key issue that must be settled quickly and then communicated effectively is the role that private health insurance funds will play in developing, implementing and funding Health Care Homes. Already there is a disconnect between what the Primary Health Care Advisory Group has recommended as possible roles and the fact that involvement of PHI funds is not specifically mentioned in the media releases that accompanied the announcement.
The potential involvement of private insurers raises a number of questions:
- Will a specific (different) Health Care Home model be developed for those patients who have private health insurance cover for some of the services they need?
- How will patients be selected to ensure that the services to be provided through the Health Care Homes are effectively targeted? Unless well managed, voluntary enrolment will mean better educated patients who already have established relationships with their general practice are most likely to be part of the proposed trials; the law of inverse care will be further enhanced if patients with PHI are given any sort of preferential treatment.
- If PHI funds are to be financial contributors to the trial, how will their contributions be managed? Will funds agree to their dollars being used to cover the cost of services for non-members? Will funds only contribute to those Health Care Homes in areas where there are high rates of membership and/or high numbers of private facilities? Again, this would mean that significant populations groups (Aboriginal and Torres Strait Islander peoples, those with mental illness, the less well-off and those in rural and remote areas) will potentially be discriminated against.
- Will the Government seek legislation to authorise PHI funds to be involved in the provision of community-based care, or will this simply be permitted by turning a blind eye, as currently?
- If, as a result of legislative changes, patients have PHI cover for services that are also covered by Medicare, who will be the required first payor?
- How will current restrictions that PHI funds place on policies (eg preferred providers, permitted treatments and services and the number of these covered) influence the ability of their members to fully participate in the trial?
The Government has said that the Health Care Homes trial will commence in 2017. There’s a lot of work to be done between now and then to ensure that clear guidance and information is provided to all the stakeholders, the most important of whom are the people with chronic and complex illnesses who stand to benefit from this new approach to the provision of healthcare services.
Responses from the minister’s office (answered by a spokesperson)
On the planned funding arrangements:
Funding arrangements for the trial will commence from July 2017. The new payment model will be managed by the Department of Human Services and include upfront payments for enrolled patients and quarterly payments linked to review.
On the role of private health insurers:
The introduction of Health Care Homes will not change the range of primary health care services that insurers can cover (e.g. insurers will not be able to fund GP services); or allow insurers to direct clinical care.
In line with current arrangements, under general treatment policies, insurers will be able to assist members who enrol in a Health Care Home with the costs of approved services received outside of the hospital setting that are not covered by Medicare (i.e. additional services). For example, an enrolled patient may access PHI-funded dental, optical, dietetics and physiotherapy services.
Insurers will continue to able to fund an expanded range of primary health care services for their members and continue to be able to fund hospital substitute and palliative care services for members who enrol in Health Care Home. In doing so, they can provide members with choice to receive care outside the hospital environment.
The Health Care Home initiative will also support better communication between primary health care services and PHI‑funded services, along with publicly and self-funded services, coordinated through a single care plan developed by the Health Care Home, maximising supports available to the patient.
It will assist Primary Health Networks to collaborate with insurers, alongside Local Health Networks, providers and patients, to support regional planning associated with the Health Care Home.
Private Health Insurers were not ‘given a head’s up’ prior to the announcement of the Health Care Homes Trial
On equity of access:
A risk stratification model will be established to support identification of patients and allocation of resources in accordance with need.
No decision has yet been made on which PHN regions will be selected for stage 1 of the rollout of the Health Care Home model. Regions will be selected to provide a good cross-section of geographic regions including large metropolitan, outer metropolitan, regional and remote communities, ensuring the effectiveness of the model can be fully assessed to inform further rollout across multiple population groups, including Aboriginal and Torres Strait Islander patients.
On evaluation:
As part of the first stage of the rollout, the Department of Health will undertake a rigorous evaluation of all elements of the model. An Implementation Advisory Group will be established to provide advice on the establishment and evaluation of the Health Care Home model.
