Hidden in a pack of draft reports from the Medicare Benefits Schedule (MBS) Review Taskforce that were released by the Morrison Government without fanfare just before Christmas are a series of recommendations that, if effectively funded and implemented, could begin the long and difficult task of reforming Australia’s primary care system.
About the MBS Review Taskforce
The MBS Review was established in 2015 to consider how the more than 5700 items on the MBS could be aligned with contemporary clinical evidence and practice to improve health outcomes. More than 70 clinical committees involving more than 700 clinicians, consumers and health system experts have been engaged in this work, which is moving at a pace that is painfully correct, endlessly consultative and frustratingly slow.
The General Practice and Primary Care Clinical Committee (GPPCCC) was set up in 2016. The committee released its preliminary (Phase 1) report in April 2017, and the Phase 2 report (dated August 2018) was included in the reports released in December.
The GPPCCC has 20 members, of whom nine are GPs, four represent other health professions, five are academics or administrators, and two are consumers (some people wear more than one professional hat). In many ways it can be considered the successor to the Primary Health Care Advisory Group (PHCAG), which was headed by Dr Steve Hambleton, who is also on this committee.
Health Care Homes
The December 2015 report from the PHCAG called for the development and establishment of the Health Care Homes model of patient-centred primary care as a mechanism for improving the management of people with chronic and complex conditions, including mental health conditions.
To date, the Health Care Homes trial has not been a success, in part because it has not been a government priority. Could the recommendations from the MBS Review, in combination with extended funding commitments for Health Care Homes from the both the Government and the Opposition, finally provide the impetus for reforms in Medicare?
Will the MBS Review recommendations deliver primary care reform?
My assessment is that what is proposed is a sound basis for needed reforms in primary care. The changes are incremental in the first instance, focused on improving the management of those people with chronic and complex conditions who struggle under the current system which does not appropriately reward their primary care providers (GPs and others) for the time and effort required to provide them with best practice care.
But underpinning the recommended changes to some 150 Medicare items that have been proposed in the Phase 1 and Phase 2 reports is a vision for the future that, if subsumed into the culture of those who work in, use, and administer the healthcare system, will lead to the more substantial changes in structure, function, funding, and workforce that are needed for major, lasting reforms.
This medium to longer-term vision looks for ‘a way of thinking and doing things that …. means putting people and their families at the centre of decisions and seeing them as experts [in the management of their chronic conditions], working alongside professionals to get the best outcomes.’ The push is for a more patient-centred model of primary care, under GP stewardship but in partnership with patients, that provides continuing care rather than episodic treatment, that addresses prevention and health promotion and not just disease management, that is delivered by collaborative teams, and that is outcome focused.
The long road to such reforms begins with small steps – in this case the recommendations around some 60 current MBS items relating to general consultations, chronic disease management, case conferencing, health assessments and medication reviews that are made in the Phase 2 report.
Recommendations on MBS items
The report makes a series of recommendations (all with accompanying rationales) around changes to long general consultations, GP Management Plans (GPMPs) and Team Care Arrangements (TCAs), recognising the time that is needed for GPs and the primary care team to do this work well.
GPMPs, currently seen as often perfunctionary, should include assessment of the patient’s physical, psychological and social function and encompass a comprehensive preventive health plan that looks beyond the scope of the existing chronic disease. GPMPs and TCAs would be combined and access to allied health items would be directly linked to the creation of a GPMP. Patients determined by the GP to need a GPMP (the need will vary with the patient rather than the diagnoses) would also gain increased access to after-hours care, home visits, care facilitation services and medication management reviews.
Multidisciplinary case conferencing items, which are currently not well utilised, would be revamped. These recommendations recognise the need to expand the primary care team, with allowances for home and community health providers, family, carers and patients to be involved.
There are also recommendations for more evidence to support the better targeting of health assessment items so that these lead to improvements in mortality and morbidity, rather than simply to more treatment.
The biggest step on the road to reform is likely the recommendation for the introduction of a voluntary patient enrolment fee. This fee (the level not indicated, but variable depending on the patient’s location and health status) would reward those GPs and / or practices for enrolling (ie. taking on responsibility for and with) a patient with chronic illness.
This recommendation is seen by the committee as taking effect in the medium- to long-term, but realistically this should be a priority, as it is intrinsically linked to benefits for both patient and doctor. These include flexible patient access such as non face-to-face channels for repeat prescriptions, repeat referrals and communication of results, and after-hours and emergency services, including home visits. Chronic disease management plans and health assessments would be limited to those practices where patients are enrolled, which would also have responsibility for ensuring that the patients’ MyHealthRecords are maintained.
These recommendations – major and minor in nature – address many current issues in primary care:
- funding doctors for investments in patient time and administrative work not currently covered by Medicare;
- relief for some of the burgeoning out-of-pocket costs patients face;
- cost-savings from limits on low-value and inappropriate care;
- recognition of the importance of coordinated and integrated care; and, most importantly
- acknowledgement of the central role that patients must play in managing their health and healthcare.
The task and the hurdles ahead
To date there has been little public focus on these important recommendations. This must change – they are too important to be ignored. Moreover, feedback to the MBS Review must not be limited solely to medical organisations.
There is a long process ahead before anything is enacted. The report is still subject to stakeholder feedback which is then considered by the MBS Review Taskforce. If endorsed, it must then be considered by the Health Minister and the Government. The report that was publicly released in December is dated August 2018, so it’s hard to know which of the stakeholder groups have already seen it and commented. It appears that there is no mechanism for these comments to be made public; this lack of transparency is antithetical to public input.
There are needed changes in culture (on the part of both healthcare professionals and patients) and clinical practice that present big hurdles to be overcome. The interim report pushes for more to be done around decision supports (via locally tailored clinically pathways), education enablers and clinical governance through the Primary Health Networks, and for greater data transparency and feedback of selected metrics to individual GPs, practices and PHNs. There is also recognition that consumers need to understand better how the MBS works.
Inertia, resistance and money worries
Realistically, these recommendations alone will not be sufficient to overcome the current inertias, outright resistance to change, and concerns about income from GPs. Many GPs claim they are already providing medical home environments and some do achieve this goal. Others fall far short. There is also much work that must be done to reach optimal levels of health literacy and patient engagement in their care.
To date the work of the MBS Review has left some obvious gaps. For example, there is really nothing in either Phase 1 or Phase 2 reports that address the mental health needs of the chronically ill and the physical health needs of the mentally ill, and there is no indication that the recommendations for GPMPs and TCAs can be readily extended to GP-prepared Mental Health Management Plans.
We know little about why GPs charge what they do and their billing practices, especially with respect to those patients they see often because of multiple chronic conditions. There is little information about whether those patients with a GPMP do better than those without, and what the impact of a GPMP is on treatment compliance and out-of-pocket costs.
The GPPCCC report recognises that GPs have ‘adapted provision of care to be viable in the framework of MBS fees and rebates presently available’ – something that I have seen reflected on Twitter with claims that fees for chronic disease management items keep GP practices viable. It is well accepted that the fee-for-service system works against effective and cost-effective models of care. Primary care financing must be structured so that the use of chronic disease management items is for improved patient health, and not solely for boosted doctor finances.
Will government invest?
The report states that: ‘All recommendations are intended to support a significant investment in general practice’ and that there will be downstream benefits from investing in primary care. Will at least some of these recommendations be included in the extended Health Care Homes trial? Will some of the $1.25 billion promised in the December MYEFO for a Community Health and Hospitals Program be used to implement these recommendations? Will a Labor Government stick with the $100 million commitment from 2016 to trial a new innovative primary care model?
What is essential moving forward is strong political leadership committed to providing the needed resources, healthcare professionals who are enthusiastic about system changes that will help them do more for and with their patients, and a voter constituency that is willing to push for these needed changes. In the absence of such a cooperative triumvirate, the hard work of healthcare experts of the MBS taskforce will be shouted down by recalcitrant doctors who fear change (as we have already seen with the MBS Review anaesthesiology report) and it will join the growing repository of ‘good reform ideas never given a chance’ in the archives of the Department of Health.
Dr Lesley Russell is contributing editor to Croakey and Adjunct Associate Professor at the Menzies Centre for Health Policy, University of Sydney