Everyone knows there’s a money problem – how do we fix it?
GPs, patients and even politicians can agree (a rarity) that general practice is in crisis.
“Our general practice right now is in the worst shape it has been in the 40-year history of Medicare,” as Health Minster Mark Butler noted earlier this year.
Money is the problem and the fix – isn’t it always?
While he’s “cautiously optimistic” about the government’s attempts to better fund general practice, Sydney-based GP and Avant CMO Dr Michael Wright does not believe they are aligning with practitioner and patient values.
Speaking on the inaugural day of WONCA, taking place 26-29 October, Dr Wright outlined where we’re at, how we’ve got here and what’s next.
While the autonomy that the fee-for-service model allows may be attractive for GPs, it provides no incentive for preventative healthcare and can encourage fast care provision at the expense of quality, said Dr Wright.
“Lumpy time bands” were a feature of the Medicare-based system, he said.
The MBS incentivises billing shorter consultations by rewarding them proportionally better, encouraging “six-minute care”.
Problem two was indexation freezes.
Between 1995 and 2022, the average annual indexation rate for the MBS has been 1.1%, rather shoddy in comparison to a 2.4 and 3.5% increase in inflation and wages respectively. Between 2014 and 2019 rebates rose by zero.
These indexation freezes have resulted in an approximately $3.8 billlion health funding loss, Dr Wright said, citing the AMA.
In the face of an ageing population, continued inequality, increasing incomes and expectations of care, the pressure on general practice is rising, with 48% of GPs telling an RACGP survey last year that continuing to work in general practice was financially unsustainable.
According to Dr Wright, Australia must learn from previous reforms and trials of alternative models.
Few such trials have produced evidence of long-term effects, but this, according to Dr Wright, is what we can learn.
Pay for performance works. Arguably too well …
In 2004, the NHS underwent the largest implementation of pay for performance in primary care by introducing the potential of up to 25% pay increase based on performance.
While output drastically improved, it produced a £1.75 billion budget blowout.
Locally, Medicare Chronic Disease Management items have allowed GPs to delegate by expanding fee for service models.
Unsurprisingly, what ultimately works are incentives that align with existing business models, intrinsic morality and provider buy-in.
“I think fee for service works, because that’s what most of us are very familiar with,” Dr Wright said. “And adding things that reinforce our intrinsic motivation also work.”
What doesn’t work? Misaligned motivations from funders, for example state and federal; poor consideration for broader downstream effects and newer models without sufficient evidence.
“Reform costs money, and particularly reforming primary care is likely to push up primary care costs, so you need to invest in primary care, before you can get any advancement in savings,” he said.
“And that’s a challenge when you got one part of government paying for some services, and another paying for other.”
And so, the answer.
1. Reform disparities in the MBS to fund longer consultations comparably to shorter consultations, said Dr Wright.
“If we could have some additional funding to reduce that lumpiness – much longer Bs, or more money for Cs and Ds – that would even that misalignment out, potentially reducing the incentive for the six-minute consultation.”
2. Fund initiatives that allow GPs to delegate care, keeping GPs at the centre but allowing multidisciplinary care.
If GPs were allowed to include the rest of their team in the time that we can allocate for a Medicare-subsidised consultation, this could facilitate delegation with accompanying remuneration, he said.
3. Base innovative funding models and reforms on evidence and ongoing consideration.
“Particularly around MyMedicare, we need to keep evaluating … we need to work with the government to say, where it’s working, where it’s not and how to improve it.”
This means improving data efficacy and working as a collective health service.
“[GPs] have all got electronic health records on our desktop that don’t interact with any [other] health systems, it’s really bad.
“But it’s not our fault.
“I know NSW is doing a statewide new electronic health system, but with very little GP input.
“Everyone’s looking at their own faction in isolation. But working together is important.”
Finally, added Dr Wright, it’s about identification of populations with high needs and targeting funding.
The Lumos study, which followed patients journeys through the NSW health care system, provides recurring evidence of the benefits of primary care even outside of general practice.
“If patients are seen [by a GP] within a week of discharge, their readmission into hospital is 32% less than if they’re not seen,” Dr Wright said.
“We are getting the evidence of the value of what we do [as GPs]. We just need it to be valued by others in the system.”
Ultimately, “given this percentage of expenditure that’s allocated to general practice, it’s the most efficient part of expenses because nine out of 10 patients see us every year,” concluded Dr Wright.
GP expenditure makes up less than 7% of overall health funding, as measured by unreferred services claimed on Medicare – even less if you pull out PHN spending, he said.
Ultimately, Dr Wright said, GPs would prefer a model of care that doesn’t increase patient out of pocket costs, but this must be married with proper remuneration.