The path forward for Medicare reform

Today at the National Press Club in Canberra a panel discussion on Medicare reform highlighted some of the key tensions that need to be resolved in order to realise the Strengthening Medicare Taskforce’s vision of “high quality, integrated and person-centred care for all Australians”. 

Croakey editor and health policy analyst, Jennifer Doggett, discusses this event and broader issues relating to Medicare reform below. 

See also the text of the speech by Dr Stephen Duckett at the Press Club event.

Jennifer Doggett writes:

Since the release of the Strengthening Medicare Taskforce Report last week, the debate over Medicare reform has played out in the mainstream and social media, revealing the fault lines in the primary healthcare landscape which could derail this latest push for reform. 

As Croakey’s rolling wrap of responses to the report indicates, most health groups and experts broadly agree with the need for a more comprehensive, integrated and person-centred system of primary healthcare. 

However, where they differ is in the detail of how this aim can be achieved.  

Issues such as pharmacist prescribing are creating divisions in the sector and between the stakeholders involved in this debate.

These unresolved tensions are no doubt the main reason why the Taskforce’s report contained few specific proposals and scant detail on the implementation of a reform agenda.  

However, they will need to be resolved if this reform process is to have more success than previous attempts.

A panel discussion at the National Press Club in Canberra today provided some indication of the challenges facing the Government in bringing the sector together to develop a cohesive reform agenda. 

Speaking at this event were two GPs, Dr Nicole Higgins, RACGP President, and Dr Kerrie Aust, AMA ACT President-elect, and health economist (and former Secretary of the Department of Health) Dr Stephen Duckett.

A number of people pointed to the lack of consumer and allied health involvement in the debate, seeing this as indicative of the lower priority given to these stakeholders by government and the media.

The GPs’ perspective

Higgins and Aust provided a very similar commentary on the current state of general practice and argued strongly for a significant increase in funding, primarily via higher rebates. 

They both stated that governments had ignored general practice for decades.

They pointed out that Medicare rebates have not kept pace with the rising costs of providing care. Aust added that MBS rebates for general practice are now less than half of the AMA recommended fee.

“For decades general practice has been taken for granted. It’s strange and illogical that this should be the case,” Aust said.  

Higgins described how medical students were reluctant to enter general practice due to the perceived barriers involved, including high levels of red tape and bureaucracy.

She argued for a redirection of funding from other areas of the health system, including hospitals, to strengthen the capacity of general practice to deliver high value preventive care. Along with Aust, Higgins expressed scepticism about the value of pharmacy prescribing and other proposed measures to allow other health professionals to provide some services typically undertaken by GPs.

“Seeing your GP is better than a wonder drug. It’s time GPs and their practices were not taken for granted,” she said.  

However, in response to a question from the media, Higgins indicated that her objection to these proposals was based, at least in part, on the practical difficulties involved in communicating across different healthcare settings.

“Once we start fragmenting care we get more complications and duplications. It is a false economy. We don’t have the systems in place – such as data sharing – to be able to ensure we can all work across the system seamlessly.  We can’t have everyone working on their own – we need an integrated system.”

Interestingly, none of the three panellists supported an increased involvement of private health insurance in general practice, citing concerns about the impact on health equity and the potential reduction in clinical freedom.  

When asked about the sum of money required for effective reform, neither Higgins nor Aust could provide a figure, although both agreed that it would need to be significantly more than the $250 million per year allocated by the Federal Government in the last Budget.  

Duckett also supported increased funding for rebates, adding that it was important to clarify the goals of raising rebate levels as it may not be the best way to increase bulkbilling.  

The way forward

As the Grattan Institute pointed out in its recent report, there have been many previous and failed attempts at reform in primary health care. If this latest attempt is to be successful it will need to learn the lessons from past failures as well as resolve the current tensions between primary health care stakeholders on hot button issues such as pharmacist prescribing. 

Today’s event made it clear that this will not be easy. 

The peak medical groups appear more open than previously to funding reform, however, they clearly want a serious down payment in the form of rebate increases before they will agree to engage in discussions about other reforms. 

This is going to be difficult for the Health Minister, Mark Butler, to justify, given the current fiscal environment, spending pressures from aged care and the NDIS and the ongoing demands of the COVID-19 pandemic. 

If the Minister can’t put enough on the table to win the doctors’ groups over, it is likely that the reform process will stall and the Strengthening Medicare Taskforce report will join the raft of other similar documents gathering dust on the bookshelf.

That doesn’t mean that nothing in general practice will change. 

Governments at both the state and federal level will push ahead with initiatives which fill the gaps in mainstream general practice, such as the urgent care clinics and state-based pharmacy prescribing trials. 

The corporates will continue their encroachment on the traditional GP-owned and run model of primary health care, with an agenda which puts profits first and patients second.

Information technology has not yet had the disruptive impact on health care that it has in other sectors but this is not far away.  Already, online GP consultations are occurring outside of Medicare and general practice business models not reliant on rebates are emerging. Future IT innovations coming down the pipeline will transform primary health care in ways we cannot even imagine and may ultimately make many of the current issues being hotly debated today redundant.

All this will happen on an ad hoc basis, without the context of an overall reform agenda and will therefore likely result in poorer outcomes for both doctors and consumers than could have been possible through a collaborative process between stakeholders.

The role of the medical profession

Given this, the medical profession should think very carefully about how it engages with government and others engaged in the current reform process.

Doctors have accused governments and other stakeholders of failing to understand the reality of general practice.

No doubt they are correct. But it is also true that GPs (or at least their representative groups) appear not to understand how governments work.This is a problem given that they are asking for some billions of dollars out of the budget.  

The lesson from decades of failed health reform efforts is that doctors might win the battles but they are unlikely to win the war.

As decades of political advocacy by doctors’ groups have demonstrated, governments are very reluctant to engage in public conflict with the medical profession. When doctors push back hard against government proposals they are quite often successful in getting governments to back down. 

However, this does not always end well for the medical profession. 

When they encounter enough resistance, governments may admit defeat but will go into a “quiet quitting” mode on the issue in question, choosing instead to spend their dollars and political capital elsewhere.    

Over the past decade or so in primary healthcare, this has looked like rebate freezes and inadequate indexation.  

As Higgins and Aust outlined today, the end result of this is our current under-funded and stressed system of primary health care.

If we don’t want to end up with another decade of inaction, all parties with an interest in primary health care will need to do their part. This includes both doctors and governments and also the general community which will need to accept higher costs (perhaps via higher taxes) if we want a high quality primary healthcare system for our future.

See here for previous Croakey stories on the Strengthening Medicare Taskforce.