Paul Smith, political editor at Australian Doctor, has had a briefing from the National Health and Hospitals Reform Commission. He writes:
The commission’s final report is due in about six weeks . Last week its chair Dr Christine Bennett held a few background briefings for journalists. The final report is still a work in progress apparently. The commission has yet to come to its offiical view but here is a few hints of what is under discussion.
The first thing worth pointing out is that the final report is going to be smaller than the 400 page opus that made up the interim report. And unlike the interim report, it’s going to offer the financial implications of each reform being pushed by the commission – the cost and the potential savings to governments and taxpayers.
It will also include what Dr Bennett described as a “road map” for implementation. So each idea will carry recommendations for action and deadlines (probably similar in approach to the commission’s supplementary paper on e-health released last month.
These two things will be welcome by many, particularly by those who thought the ideas in the interim report could safely be ignored by governments because it offered no strategic framework for implementation, no time line or an idea of cost to show it was in touch with political reality.
The following is far from an exhaustive list of course, but on concrete policy ideas it looks likely that we will see…
• Voluntary patient enrolment for patients with chronic conditions or those, like pregnant women, needing longer term care. There will be funding to help develop care packages for those patients who sign up.
• Pay for performance for GPs – at least for GP practices that embrace voluntary enrolment. Some of it will be based on process measures – vaccination rates for instance. But GP practices offering voluntary enrolment will also recieve additional funding based on the clinical outcomes of their enrolled population. I didn’t discuss this with Dr Bennett but I think the clinical measures (at least initially) probably won’t stray very far from those used in the Australian Primary Care Collaboratives program.
The idea of pay for performance is to offer extra funding for those who sign up. Pay for performance, at least in the short term, is not about replacing current funding for general practice – ie fee for service.
• Greater use of advance care directives and the improvement of palliative care services for aged care patients. The idea is to keep the keep elderly patients close to dying away from the interventionist horrors of the hospital system.
• Improved funding for major hospitals facing overcrowded emergency departments is also likely to be recommended. Access block, Dr Bennett believes, is largely the result of sky high bed occupancy rates – the 90%, 95% , 100% plus rates faced by many city hospitals. So sufficient cash from the hospital funders is needed to keep the necessary beds vacant. Dr Bennett appears to accept the argument (made by emergency physicians) that a lack of available beds, rather than an influx of primary care type patients unable to access GP care, is the problem that needs addressing .
The commission will probably back away from introducing an 85% occupancy rate target for major hospitals as recommended by the AMA, which believes that going beyond 85% is where the inefficiencies and danger to patients start to escalate. Dr Bennett said the bed occupancy rate measure is complex and is too open to gaming.
The interim report did not go into great detail about future job roles in the health system or the thorny issue of “task substitution”. Dr Bennett doesn’t like the phrase “task substitution”. She said that through the commission’s consultations it was obvious that too many health workers felt their skills and experience were being underused with productivity losses as a result.
Under the commission’s thinking, nurse practitioners should expect to get PBS and Medicare funding for their work (the current budget is rumoured to be addressing this already) as well as the ability to make referrals to specialists whose care can be funded by Medicare. The idea however, is not to give nurse practitioners provider numbers nor is it about creating a system where they act outside the primary care team.
There is a clinic in WA, run by a company called the Revive Group, staffed entirely by nurse practitioners offering a first contact point for patients. I didn’t get the impression that Dr Bennett wanted to encourage the idea.
Many of the ideas in the interim report and those that make it as far as the final report don’t need a paradigm shift in health care delivery, funding or governance to implement. And there is an argument that the commission’s existence – along with the other reform taskforces and expert committees set up by Federal Government – has put into political cold storage basic health reforms that should have been adopted already.
Roxon is keen on her Government’s reputation for its reformist health agenda but it’s often honoured in the rhetoric than in practice – the list of reforms being implemented over the last two years seems slim to me.
On the big issue – governance of the health system – the commission’s interim report laid out three options.
Re-align responsibilities for health between states and commonwealth. For example the Commonwealth becomes responsible for all primary health care funding and policy.
The Commonwealth to be solely responsible for all aspects of health care, delivering through regional health authorities. Transfer all responsibility for public funding, policy and regulation to the Commonwealth, with the Commonwealth establishing and funding for regional health authorities to take responsibility for former state health services
Commonwealth to be solely responsible for all aspects of health and health care, establishing a tax-funded community insurance scheme under which there would be multiple, competing health plans for people to choose from, which would be required to cover a mandatory set of services including hospital, medical, pharmaceutical, allied health and aged care.
As noted in Croakey already, Adam Cresswell in the Australian on Saturday wrote about Dr Bennett’s apparent enthusiasm for option C after his discussions with her last week. I came away from my briefing with the same impression. Don’t think I even asked any direct question before she mentioned the “positive feedback” and “interest” from many submissions on option C, the option dubbed by the Sydney Morning Herald as the “mega change”.
Dr Bennett (whose day job by the way is chief medical officer for MBF) said the option had been misunderstood by much of the media. And she also spoke about how discussions about the concept of managed care – the approach said to underlie many of the (alleged) problems of the American health system – had become a “managed scare”. She felt the label was unfair and not good for the debate.
Perhaps it is worth stressing this – Dr Bennett also said the commission could come up with governance reform that takes elements of all the options – A, B and C. God knows what that will look like.
So perhaps the advice is this – don’t start buying up those Kaiser Permanente shares just yet.