In a report released today, the Grattan Institute has argued for major changes to Medicare to support Australians’ growing need for chronic disease prevention and management.
These issues have also been raised by Dr Tim Woodruff, a specialist working in private practice, past president of the Doctors Reform Society and current Chair of the Australian Health Care Reform Alliance.
In a piece originally published in Pearls and Irritations, Woodruff echoes the call in the Grattan report for primary health care reform, including an increased role for nurses, physicians assistants and allied health professionals in primary health care.
He also proposes funding for salaried specialists in hospitals and community settings, highlights the need for a greater focus on prevention and calls for the reinstatement of Health Workforce Australia.
Tim Woodruff writes:
From a patient perspective we could have a system which enabled patients enrolled at a medical practice to see their usual Specialist GP (SGP) within weeks of a request, but able to see an alternate SGP, a nurse practitioner (NP), or a physician’s assistant (PA) within days and on the same day if necessary, with no out of pocket costs. The medical practice could have on-site physiotherapists, psychologists, dietitians, and other allied health professionals also freely available.
Case workers could be available to take on patients with more complex needs, to co-ordinate access to housing services, employment agencies (re-imagined), and the like and to facilitate case conferencing.
Patients could be discharged from hospital with a two page discharge summary (also sent electronically), written by a senior doctor in the team, designed to inform the SGP only of the relevant information from the hospital admission, providing a seamless transition from hospital to home.
Medical centres in areas of SGP shortage could be staffed with highly qualified salaried NPs or PAs who could effectively and efficiently handle acute and chronic issues with appropriate SGP back-up from the nearest SGP medical practice (just like SGPs would have access to non-GP specialist back-up wherever they are).
Timely access to non GP specialist care both for consultations and for procedures could be restored.
For residents in Aged Care facilities their timely access to healthcare could be through adequate salaried nursing staff, NPs, PAs, and SGPs employed part or full-time.
From the SGPs perspective, part or full-time salaried employment at a level comparable to that which public hospital non-GP specialists currently earn i.e. $230,000 plus, could be much more attractive than their current status. For the non-GP specialists in public hospitals, there would be little change except for their increased responsibility for ensuring excellent communication with SGPs, and also for some, to be working on salary but in the community in larger medical centres.
From the perspective of NPs, PAs, and the various allied health workers this could finally be an opportunity to work to their full professional capacity in mutually supportive teams, seeing their patients cared for in the holistic manner often aspired to but seldom realised.
Where are we now?
Patients frequently struggle to get continuity of care and sometimes any care at all. Many can’t afford the care available or can but at a cost to their other needs. Many wait years in pain with decreased function, stressing themselves and their families.
Patients and their families have to negotiate the multiple siloes of care which have disparate funding models. Co-ordination is often up to the patient and family. Those who need the most care receive the least.
Those who need the least care receive the most. Our tax and funding system facilitates this gross inequity. SGP numbers are falling.
How can we improve?
We can start with Primary Health Care (PHC) where a window has been opened with the conservative Australian Medical Association now supporting patient enrolment with either a SGP or Medical Practice (MP).
For enrolment to work incentives are required for both the providers and the patients. An enrolment fee can be paid to the provider. This already happens for Aboriginal and Torres Strait Islander (ATSI) people. Currently there are relatively small financial incentives to providers called the Practice Incentive Payments and the Workplace Incentive Program. These are already adjusted for age and gender. They can be adjusted for socio-economic status (SES) of the patient’s location, available already at the level of 30-60 dwellings called MESH blocks.
This would recognise the extra work required by providers to address the generally more complex health issues of those of low SES. No MP or SGP would be worse off and over time these payments can be increased, expanded, and blended into a capitation payment per enrolled patient to negate the need for co-payments, and to include payment for the many health care providers other than the SGP.
The final step could be to then stop fee-for-service payments altogether for enrolled patients, or at least to those being treated for chronic diseases. Rorting is so much harder in a salaried service. Under servicing could be an issue particularly in smaller medical centres but as in public hospitals, one is working in a team and under servicing is likely to be called out.
How does the patient benefit? The initial payment for enrolment needs to be partly and variably contingent upon delivering certain levels of continuous care to the patient. This already occurs with ATSI patient payments. The additional payments could then also be made contingent on such care.
The other area that is begging for a revamp is hospital and non GP specialist care. This is expensive. Public hospital care proves one doesn’t need the fee-for-service model to get quality. We need to directly fund more non GP specialists on salaries in publicly funded hospital facilities and in the community. Prohibitive, inequitable co-payments cease. Rorting disappears. Patients are treated in a timely manner. The private health insurance rebate can be gradually reduced to fund this expansion of non GP specialist care and of an expanded PHC.
The big picture
Ultimately however, the grossly inefficient debacle of Federal, State and Territories, and Local Government funding of health services needs to be addressed. A National Health Care Reform Commission needs to be established as the single funder of public health care, independent of politicians and the many stakeholder groups. Charged with distributing funds on the basis of need, it would be a long- term project. Politicians only decisions would be how much to fund the total health care budget and who to appoint to the Commission.
As well as the Commission we need a restoration of Health Workforce Australia and a Preventive Health Agency because without developing our workforce nothing can happen, and without prevention we are asking for a tsunami of preventable illness and death.
The first steps could start now or at least with the next budget especially given that the first steps are not expensive. It would take vision and leadership from Labor. Despite the AMA’s commitment to patient enrolment, they would object to capitation and other changes because it reduces doctors’ autonomy even if most SGPs could be financially better off. The PHI industry and private hospital industry would object because it would very simply affect their bottom line i.e., profits. But our health services should be first and foremost about patients. Our system, a revamped Medicare should be focused primarily on patient need, not on the antiquated view of some providers as to how a 21St century health system should be.
It is all possible. It is a process which can be started now with little cost. The lives of our patients depend on reform. Our society can be healthier. We can have a health system rather than an inequitable, inefficient, unco-ordinated collection of health services. We have dedicated health providers. We are wasting their talents and both our patients and our country are losing out.
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