Introduction by Croakey: From October 1, consumers will be able to sign up for MyMedicare, a voluntary patient enrolment scheme developed by the Federal Government as part of its response to the Strengthening Medicare Taskforce.
Previous efforts to reform general practice have not delivered lasting improvement to a sector that the Grattan Institute describes as having “more pilots than Qantas”.
So has the Department learnt the lessons of the past and drawn on international experience to ensure that MyMedicare will be the reform that sticks?
For the #LongRead below, Croakey editor Jennifer Doggett asked primary healthcare stakeholders and experts whether this new scheme will deliver improved quality and continuity of care for patients and take pressure off Australia’s over-burdened public hospital system.
Jennifer Doggett writes:
The first question to ask about MyMedicare is whether the direction of change is the right one, according to Professor Stephen Duckett, Honorary Enterprise Professor, School of Population and Global Health at the University of Melbourne and former Secretary of the Department of Health.
He believes that the answer to this question is an emphatic ‘yes’.
“Despite the fact that the research base for patient enrolment may not be as strong as we would like, it’s the direction that the rest of the world is moving and for good reason,” Duckett said.
“Of course, it’s important to be careful about hopping on a bandwagon just for the sake of it and that is why a robust and continuous evaluation is important, so we know what the program is delivering every step of the way.”
Duckett noted that a key lesson from the Health Care Homes (HCHs) trials is that both design and implementation are crucial to a program’s success and said that looking back it was clear that the poor design of the HCHs trial meant that it didn’t have a chance of working from the start.
He identified one potentially “tricky” aspect of the design of the MyMedicare program is its initial focus on people who are frequent hospital users.
“We learnt from the Coordinated Care trials that there are many reasons why some patients attend hospital frequently and not all of these can be addressed through changes to general practice,” he said.
Duckett emphasised the need to recognise that frequent hospital attendees are not a homogenous group, making the point that quite different responses will be needed for people with mental versus physical illnesses and there are also likely to be differences between rural and urban areas.
“There’s a lot of work to be done to tease out these issues and, given the high expectations of the program, it’s important that the Department proceed with some caution and be upfront about what can be achieved. This includes listening to consumers and being clear about how MyMedicare can be a mechanism for delivering on some of their priorities,” he said.
Clarifying the value proposition
Professor Anthony Scott, from the Monash University Centre for Health Economics, suggested in an article several weeks ago that MyMedicare had the potential to provide patient benefits but that more details were needed to determine how it would work in practice.
Scott also raised concerns around potential unintended consequences of the scheme, such as increased hospital presentations (due to unmet demand) and reduced access to GP services (if the increased income means that GPs see fewer patients).
Scott continues to have concerns that the value proposition of participation in MyMedicare for many patients is not clear, saying that while people with chronic disease who see a regular GP are likely to participate, it’s not obvious that it will improve their care.
“They won’t get priority appointments and the commitment to improve multi-disciplinary care are very vague. More work needs to be done to clarify the value-proposition to consumers,” he said.
Another issue raised by Scott is the potential for selection bias.
“As we have seen with previous reform attempts, it’s often the already high performing doctors who volunteer for these sorts of programs. This means that those doctors who need programs like this the most may not get additional support and their patients will miss out on the potential benefits,” he said.
Scott emphasised the important role of data in the rollout of the MyMedicare program.
“Unless we have better information, accessible to patients and researchers, on the quality and cost of care it’s hard to know if programs such as MyMedicare are working. There is some data on practice activities and outcomes held at the PHN level but it’s not clear whether the PHNs using this data to provide feedback to practices and it doesn’t appear to be fed back into policy and program development processes at the national level.”
He also raised the nursing shortage as another issue that could affect implementation, in particular as it relates to multidisciplinary care.
Given the increased demand for nurses from aged care and international workforce pressures, Scott argued that it might be difficult for general practices to attract nurses who are essential for the delivery of team-based care.
“Given that there is probably not a great appetite in the community for major changes to the current system, it is probably a sensible move from the Government to look at incremental changes such as this. But that also means that it can be difficult to articulate exactly where the patients benefits lie.
“The key to making the program work is to make the patient voice front and centre – it really needs to be driven by consumers to be successful. This would be a departure from previous reform attempts where consumers haven’t had a strong voice,” Scott told Croakey.
Consumer insights
Dr Elizabeth Deveny, CEO of the Consumers Health Forum, raised many issues of concern.
“Voluntary patient enrolment is not something consumers have asked for. When we poll consumers, they tell us that they want affordable and timely access to primary healthcare,” she said.
“When we ask specifically about voluntary patient enrolment, Australians say that they understand why it is good for some consumers, but many do not want to participate themselves. This is for many reasons, including perceptions that it may limit their choice of GP and primary health care provider.
“It’s important to understand that consumers often make considered choices about where they seek health care. Some people prefer to see different GPs for specific issues, such as mental health or reproductive health care. Some actively seek out a GP because they speak their native language or share a cultural identity. In these cases, they may not want to receive services from other providers, such as practice nurses, in the same practice. The implementation of MyMedicare needs to take this into account or it may not be widely accepted by consumers.”
Deveny said patient registration has the potential to improve some patients’ experience of care, as it will provide GPs with funding to deliver additional services and/or reduce out-of-pocket costs. She also suggests that over the longer term it may help prevent future illnesses due to an increased capacity to provide preventive care.
She says the aims of MyMedicare are worthwhile, but it is a significant change and we need to be realistic about the outcomes that can be expected in the short term.
She adds that for consumers who are not in the target categories, the benefits of MyMedicare will be minimal initially.
She also warns that the potential benefit to consumers from MyMedicare will be contingent upon engagement from GPs. “If a consumer decides they want to participate in this initiative and unlock benefits such as increased bulk-billing incentives, they can only do so if their GP is registered with the program,” she says.
CHF is concerned that, less than a month out from MyMedicare starting, there been little information available to help Australians understand what this program might mean for them.
“It’s not a simple program to explain, with eligibility criteria, phases of implementation and new models of care. CHF hopes to work with the Government to inform and support health literacy and communications in this space. What is needed is a concerted and targeted communication effort to ensure that consumers who could potentially benefit from this initiative don’t miss out,” Deveny said.
“The bottom line is that this program is being funded with taxpayers’ money and it should reflect their needs and priorities. MyMedicare may deliver some of what consumers want but it’s not a quick fix nor will it solve every primary care issue.
“There is a lot of work ahead for MyMedicare to reach its full potential. CHF looks forward to working with health consumers, clinicians, communities and the Commonwealth to make sure that MyMedicare makes the difference that we need it to make.”
Learning from the past
In a recent report, the Grattan Institute outlined the reasons why recent attempts at general practice reform have failed to deliver lasting results.
Recurring themes in all of these trials include poor initial designs, inadequate engagement with patients, carers, clinicians and practice-owners at all stages of development and implementation and a lack of support for change management in general practice.
The report made several recommendations to maximise the chance of success for future reform endeavours, including improved planning, “deep engagement” with stakeholders, long term funding commitments and shared leadership between the various GP and primary healthcare groups.
When asked whether the Government had learnt the lessons of previous reform efforts in its approach to MyMedicare, the Institute’s Peter Breadon said the Government should be commended for this reform, which follows an international trend away from primarily using fee-for-service payment systems for primary healthcare.
“There has been little detail about how the initiative will work to date, but I’m sure consultation and design work is happening and hopefully there will be more transparency around its implementation soon,” he said.
Breadon said that one issue standing out to him is the initial focus on patients who are frequent hospital users. He believes that after this first phase of the program it will be important to broaden it out to a wider patient group where he says the greatest gains are likely to be achieved.
“To change the incentives and resourcing for practices to deliver genuinely multi-disciplinary and preventive care, we really need a funding model that applies to the majority of patients. If it just focuses on a high risk cohort where hospitalisation is hard to predict, it will also be tricky for practices to take on the risk management required to make a blended payment system work,” he said.
Breadon acknowledged that there may be good reasons for starting with this smaller cohort of patients, but argues that in order to develop into a model that really supports the sustainable delivery of multidisciplinary care in general practice, it needs to eventually be implemented more broadly.
Medical perspectives
The success of MyMedicare will depend to a large extent on its acceptance by general practitioners and Croakey heard from GP leaders that the Government has some way to go in convincing the profession of the benefits of this program.
AMA President Professor Stephen Robson told Croakey that voluntary patient enrolment, rolled out by the Government as MyMedicare, has the potential to improve patient care by cementing long term doctor-patient relationships.
“We are working to ensure MyMedicare provides a platform for positive reforms aimed at strengthening the central role of general practice in the Australian health system and improving access to care for patients, with the Government already announcing some early initiatives including expanded access to telehealth, support for GP services to aged care and support for patients who are frequent hospital users,” he said.
Robson added that the AMA will continue working with the Federal Government to ensure programs attached to MyMedicare improve access to care for patients and that these expand over time, while also ensuring that this does not lead to a flawed capitated model used in the UK.
Dr Mukesh Haikerwal is a GP leader and former Federal President of the AMA. He reflected on the discussions about voluntary patient enrolment as part of the National Health and Hospitals Reform Commission (NHHRC) process in 2008/09.
“Voluntary patient enrolment can be one mechanism to enhance services to patients whose needs may not be met through a solely fee-for-service system. These include older people, Aboriginal and Torres Strait Islanders, people experiencing homelessness and people with chronic and complex conditions. Evidence suggests that there can be benefits to both providers and patients in providing funding outside of the fee-for-service structure for these groups,” he said.
Haikerwal noted the many changes that have taken place since the NHHRC report was released, including the COVID-19 pandemic, which has facilitated the delivery of telehealth services, and said that these changes are reflected in the design of MyMedicare.
He stressed the need to learn lessons from previous primary healthcare reform attempts, such as the Diabetes Care Project and the Health Care Homes programs, in particular in relation to their implementation. “To avoid similar problems with MyMedicare, we need to build in continuous evaluation so that the program can be amended as it goes – we can’t afford to wait five years to find out that it’s not working,” he said.
Haikerwal described GPs as having a “big heart and an open mind” and a desire to work to make tax dollars go further. But he warned that doctors can’t run a business if it is over-burdened with red tape.
“If MyMedicare is seen as a money grab to put more dollars into the Department and to add more red tape, then it will fail,” he said, adding that the key to getting buy-in from GPs is to have “a decent plan, communicate it and work collaboratively with GPs and other stakeholders on the implementation and ongoing evaluation”.
From what he heard about the last webinar the Department held for GPs, he does not feel confident that this is happening with MyMedicare.
“From the provider point of view the key question is: how would MyMedicare help me to streamline what I am already doing and provide better care to my patients. Personally, I haven’t enrolled yet as I don’t have the answers to these questions,” he said.
President of the Royal Australian College of General Practitioners, Dr Nicole Higgins, also believes that MyMedicare could help to deliver better outcomes for patients with chronic conditions and for the broader health system. “We have been working with our members and providing feedback to government to help them design and implement MyMedicare to develop a system that works for GPs and our patients,” Dr Higgins said.
Higgins emphasised the benefits for people with chronic conditions of a long-term relationship with their usual GP which she said delivered continuity of care supported by a multidisciplinary care team. “Having access to longer Medicare-funded telehealth items through MyMedicare will increase patients’ access to their GP, and funding that supports GPs to deliver care in the community can help keep them out of hospital,” she said.
Higgins also supported the increased funding for bulk billing for children and concession card holders which she said should also help people who are more likely to live with chronic health conditions access their GP.
She told Croakey that she is optimistic for what MyMedicare can offer GPs and patients, and that it’s an opportunity to access and quality care for patients. She has been encouraging GPs to look at how it can help them care for their patients, and suggests that patients with chronic conditions should consider registering with their GP when it launches.
Higgins said it was a “good sign” that the government and health department have engaged with GPs on MyMedicare and that the RACGP and members are providing them with frank feedback.
“For MyMedicare to work, it must work for GPs and our patients, and the Government knows this. The RACGP is in consultation with the government regarding MyMedicare to ensure the voice of GPs is present – and heard – in the implementation of this policy. We do not and will never support a system that is based on or leads to capitation,” Higgins said.
Data matters
Dr Kerrie Aust is President-Elect, AMA ACT, and a Canberra-based GP. She said that GPs recognise that MyMedicare is still a work in progress but are hopeful that the program will “facilitate our ability to make better links between patients, their GP and the other members of their treating team.”
She told Croakey that “in theory” the initiative should facilitate improved long-term care for patients, given that one of the benefits of having a regular GP is that patients are more likely to understand how to access their services such as how to book urgent appointments or access script refills.
“We hope registration helps to reduce the fragmentation of care through multiple service providers that can be a risk to patient safety. We all deserve a to have a GP who knows our history,” she said.
Aust stressed the need for Government to provide improved data to practices about their patient base and also for the data generated to identify and address the gaps in general practice funding that make it too easy for patients with complex care needs to fall through the cracks in the healthcare system.
She nominated specific patients group whom she felt could benefit from the program in the future, including patients living with the most complex health conditions, residents in aged care facilities and also people with significant mental health conditions who are more likely to also have poorer physical health outcomes.
“I would particularly like to see the program extend to better address the inadequacy of funding for mental health support, as the reality for our patients is that they don’t present with a mental health condition or a physical health condition, they present with both. We need a health system that enables us to better manage multiple conditions together,” Aust said.
“We see MyMedicare as the starting point for reform to improve access patient access to quality, long-term general practice care, but it is not enough to capture data. The measures need to be targeted to programs that reduce fragmentation of services, that are backed by evidence to improve outcomes for patients, and adequately funded so that the general practices providing the services are able to keep their doors open.”
Change management crucial
One aim of MyMedicare is to support a multidisciplinary approach to primary healthcare; nursing groups told Croakey that this will require ongoing involvement and consultation with nurses.
President of the Australian Primary Health Care Nurses Association, Karen Booth, said she hoped MyMedicare will support the role of primary healthcare nurses to work with GPs and other health professionals to provide more comprehensive care to people with chronic conditions.
“MyMedicare will be part of the picture to improve access to care. Longer telehealth appointments will benefit vulnerable groups, including those with disabilities and people with mobility issues who have difficulties getting to face-to-face visits. This, coupled with the rise in the Medicare rebates for GPs and the tripling of bulk billing incentives for children under 16 (and health care card holders), will hopefully encourage practices to halt the slide in bulk billing for vulnerable and financially disadvantaged people and their families,” Booth said.
“Much of the additional support under the program will depend upon GPs and practices seeing the value in the program, in terms of benefits to the patient, the GP and then the practice. They will want to know how this will differ from business as usual and what changes they will have to make to accommodate an expanded service offering through MyMedicare.”
Booth said that ideally this would involve better team-based approach/models of care, including more free flowing access for enrolled patients for services such as nurse-delivered care without the need to see the GP at each visit.
“Many patients attend a practice or clinic for healthcare, but they don’t always need care by a doctor. Hopefully we can change the doctor-service focus needed for billing purpose to a more patient-needs approach. The patient will still get the care they need and can be referred to the GP if required,” she said.
Key to the successful implementation of MyMedicare, according to Booth, is to build in a good change management strategy, learning the lesson from past programs which did not achieve real buy-in from the sector.
She also stressed the need for MyMedicare to encourage innovation and flexible models of care, given the current health workforce shortage.
“We need to have a better look at how to better use the skills of all our health professionals. This will build higher levels of professional satisfaction and help with workforce retention. For example, we know there are lots of towns in rural and remote areas where access to GPs is poor and care is led by nurse practitioners.
“We need to ensure that no-one is left behind, so once it’s up and running, we need to extend MyMedicare to nurse practitioner services so their patients are not disadvantaged. This requires a really good engagement strategy and support to bring patients, health professionals and managers along on the journey,” Booth said.
Avoiding barriers to care
Leanne Boase, CEO of the Australian College of Nurse Practitioners, told Croakey she was concerned about the potential of MyMedicare to create barriers to access if it remains closely tied to the Medicare incentive program.
“The main concern of nurse practitioners around MyMedicare is that we are not in the first part of the rollout. Minister Butler has committed to including nurse practitioners in My Medicare in May of this year, to commence later in 2024 but there is a lot of work to be done to make sure that can happen. This is due to the fact that even though nurse practitioners are primary healthcare providers, we are not fully recognised as such by Medicare, for example, we don’t get the practice incentives that are available to GPs,” Boase said.
Boase said that because MyMedicare is linked to the Medicare incentive program, ACNP members are concerned that it could create a barrier to patients accessing healthcare, particularly those who can’t currently access GP services.
“We feel that setting up a primary healthcare program just for GPs is risky and dangerous as this could form an additional access barrier. We know that there are nurse practitioners in rural and remote areas who can only do half of what they are capable of because of existing Medicare restrictions. The bottom line is that ACNP will support any initiative which increases access to care for consumers but we will not back a program that creates additional barriers to access,” Boase said.
Some history
MyMedicare was developed in response to the following recommendation of the Strengthening Medicare Taskforce:
“Support better continuity of care, a strengthened relationship between the patient and their care team, and more integrated, person-centred care through introduction of voluntary patient registration. This needs to be supported with a clear and simple value proposition for both the consumer and their general practice or other primary care provider. Participation for patients and practices needs to be simple, streamlined and efficient.”
The Government has stated that the key aim of MyMedicare is to “strengthen the relationship between patients, their general practice, general practitioner (GP) and primary care teams”.
The 2023–24 Budget allocated $19.7 million over four years to support the implementation of MyMedicare, with an additional $39.8 million designated to enhance systems delivery through Services Australia.
According to the Department’s website, the benefits of MyMedicare to consumers include better continuity of care with their designated practice, including access to extended MBS-funded telephone consultations and a triple bulk billing incentive for more extended MBS telehealth consultations for children under 16, pensioners and concession card holders.
For practices, the Department states that registration with MyMedicare will provide them with more information about their patients facilitating the delivery of tailored services as well as access to longer telehealth items and incentives, including the General Practice in Aged Care Incentive, to support the delivery of healthcare in residential aged care homes.
Accreditation against the National General Practice Accreditation Scheme is a prerequisite for eligibility for MyMedicare, except for non-accredited practices, which are granted an exemption until 30 June 2025, provided they deliver general practice services in specific settings such as rural areas, residential aged care, disability residential facilities, to First Nations people, or to individuals experiencing homelessness.
Note: the article has been updated with additional comments from the RACGP
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The “headline” says “deadline” but it’s more a “starting line” after the soft launch that is currently happening.
It may be a “lifeline” for many practices who’s patients are eligible for the extra support available.
It may also open “communication lines” between the Acute Sector and the Primary Care Sector to “encourage” our diversely funded health sector to work more closely together. It will also allow access to those longer phone calls between practices and their own patients. It is much easier for me to care for someone I know well over the phone than a person I have never met.
Thank you in any case for the “outline”. Once it starts we will have a “baseline” that we can examine over the “timeline that we can use to “underline” the beneficial outcomes for the “long line” of health care users.
Is MyMedicare lying low and hoping to avoid questions about whether its requirements imply that self-employed GPs are actually employees?
The payroll tax crisis has raised questions about what a general practice actually is, and specifically whether the service companies to which most self-employed GPs pay service fees are general practices.
For some weeks, I have been seeking answers from MyMedicare to these questions, so far without any reply.
1. Are self-employed GPs conducting their own practice?
This question relates to advice from MyMedicare that GPs should consult their practice about aspects of how MyMedicare will work.
2. Service companies that are not owned by any GPs and that don’t employ any qualified GPs are providers of serviced offices to self-employed GPs.
Despite this, do MyMedicare, DOHAC and Services Australia regard these providers of serviced offices as being general practices? If so, on what grounds?
3. If service companies are not general practices, why is MyMedicare inviting and allowing patients to enrol with them?
It appears that agencies that accredit general practices have been accrediting service companies that are not general practices. The solo general practices of GPs who are paying service fees to service companies are not accredited.
What do these two aspects mean for MyMedicare’s requirement that only accredited practices can be registered with MyMedicare?