Part 2 of our 8 things shaping the future of general practice listicle looks at tax, scope of practice, education and training and AI.
Our more literary-leaning readers might have noticed that I borrowed a quote about change in last week’s First Draft from Henry David Thoreaux, “Things don’t change: we change”.
Thinking how clever I was being, I ran it past my partner, who frowned, looked at me sideways, and said, “what, you don’t believe in climate change?” and then proceeded to reel off a whole lot of things that do change day to day while we don’t, like rain into snow, boiling water for a coffee, baking cake mix, and so on.
I’m going to say that in the context of the forces impacting general practice at the moment, of which there are many, the quote remains at least mildly relevant, despite my partner’s searing physics logic.
The change for GPs is all about how they engage, respond and adapt (or not) to many outside forces impacting their way of work and life.
5. Tax
Speaking of reacting to outside forces, tax is a pretty interesting case study so far for general practice.
When stories first started emerging about state revenue offices taking individual practices to court to claim payroll liability about four years ago, the reaction of the general practice community was initially to ignore what was happening, and, I guess, hope it would go away.
When the idea didn’t go away and started spreading to many states and the problem started becoming systemic, the response became, ‘the law is an ass’.
So the RACGP and the AMA commenced a political campaign to embarrass politicians into changing the law for GPs.
At this point the problem became a case of be careful what you wish for.
After four years of back and forth, we now have a situation where your payroll tax liability is very much determined by your postcode. Only in one state – Queensland – did the lobby groups manage to actually get rid of the tax across the board. In other states, we ended up with different versions of state-sanctioned blackmail to try and force practices to bulk bill at higher ratios than is financially sensible.
Notably, throughout the process the tin tacks of the legal and accounting issues were never fully surfaced by the main lobby groups, or probably actually understood.
Even in Queensland, the decision by most practices to roll over and more or less admit to the state government that they thought they probably did owe payroll tax – a decision made a lot easier by the government saying if you do it, we won’t tax you – might have very awkward federal tax repercussions (ATO) down the track.
A key theme throughout the process was whether a practice was a ‘service entity’ acting like a shopping centre with tenants (a Westfield with a Woolworths for instance), or actually a medical practice, controlling the doctors working at the practice via things like restrictive contracts, scheduling, advertising of doctors as a part of the practice services and centralised co-ordination of doctors on how they managed their patients, especially for things like care plans.
Notably throughout the whole payroll tax saga, several SROs suggested, incorrectly, that there were no instances where a practice structure could avoid payroll tax, and the RACGP never really went to bat for the ‘services entity’ structure (it might be thinking about that now, though).
But the services entity structure, which some experts think many practices are actually running, and don’t know it, or, always intended to run based on medical liability issues, and then got waylaid by their accountants or lawyers into a hybrid structure that would get them into trouble, does seem to solve a lot of problems.
The thing is, the service entity structure seems to address both the payroll tax problem, and any upstream problems with the ATO, most of which are yet to really surface in the manner payroll tax has because we haven’t had any major cases at the federal tax level yet.
That problem is that if you’ve put up the white flag on payroll tax to an SRO, which most of our bigger corporates and a lot of mid-sized practices have done, based on the maths of tax at the state level, you are very likely admitting to the ATO that your “contractor doctors” could easily be “deemed” as “employees”.
This can lead to all sorts of new tax problems, like you need to be paying your contractors super, they need to be charging the practice GST on the practice commission, and if they have been operating as businesses themselves, or as sole traders, their tax is all wrong as well.
A large proportion of the sector think most of the payroll tax saga has settled. A lot of the corporates, who lobbied hard with the college and state governments for changes, settled on the state-based changes to tax law, ostensibly because they already had high bulk billing rates and – even outside of Queensland – they could live with the rebates being offered in other states for higher bulk billing ratios.
The big problem for general practice, and perhaps especially the corporates, is that the tax ramifications of structure are potentially far from over, if the ATO decides to kick into play “deemed employee” interpretations and start classifying “contractors” as “employees”.
You get the sense that this potential new existential tax threat is so far being treated like payroll tax when it first started to emerge as a problem – it just won’t happen because the ramifications for the health system are just too stupid to contemplate.
Which is exactly how payroll tax ended up a huge problem.
6. Scope of Practice
We aren’t that far off the one-year mark from when Professor Mark McCormack’s major recommendations for scope of practice emerged and nothing much has so far come of the report in that time.
That’s probably been pretty comforting for the critics who perceived that the report had oversimplified and undervalued what GPs do and made recommendations which would fragment care, cost more and maybe even stratify care into GP-haves and GP-have-nots.
McCormack of course would insist that the plan would bind care more tightly together via MyMedicare, not fragment it.
Sitting back and relaxing at the dearth of activity around the report would likely be underestimating the goals of the Department of Health, Disability and Ageing, which aims to use redirected funds from tired PIP and PHN programs (and possibly inject new funds) into a far more targeted blended funding model that, using MyMedicare as a glue to target surrounding allied health services, will tie GP activity in a smart way to relevant and synergistic allied health services.
Think practice nurses and pharmacists doing more things GPs could only do and funding psychologists to work far more tightly in a line with a GP on mental health management.
Of course, this implies to a degree that the shift from 90% fee for service and 10% blended funding to 40% blended and 60% fee for service, will be targeting some of that blended funding at non GP-aligned services.
It’s difficult to imagine that there will be enough money to go around to do all that and keep GPs paid well enough.
It’s also hard to imagine at the moment that MyMedicare will become popular enough with patients to form the glue in the plan as far as patients are concerned.
So far only 30% of patients have registered for the program and from a branding perspective it’s not a thing at all with patients, just something their GP practice has got them over the line on. It will have to be providing patients with genuine day to day value and incentives to join up and take part meaningfully.
But the government has a pretty comprehensive plan for all of this to somehow come together one day.
One thing that could drive patients to MyMedicare is a universal patient app that provides patients with real day to day value, something akin to what people’s banking app does for them.
The sharing by default digital health initiative the government is pushing behind the scenes with software vendors and providers might end up doing this with services like an accurate real time universal provider directory, immediate pathology and imaging results, a summary record of every GP visits, ability to do and track referrals to specialists and hospital in patient facilities, easier Medicare payments and billing, and so oon.
There’s a lot of real time useful information that such an app might be able to bring to a patient if the government can get sharing by default working in even a minimalist format.
The takeaway for GPs is probably that Scope of Practice, although seemingly vague and difficult to do as things stand today, remains a cornerstone of the government master plan, as it’s tied to MyMedicare, workforce, funding and a desire to spike better team-based care out in the community.
As the technology and funding base roll out, McCormack’s work is going to be referenced for new initiatives, some of which won’t seem in the immediate best interests of the profession.
The trick for GPs will be to hold the government to its lofty goals for more efficient team-based care in the community. Any serious fragmentation of GP care or significant shift in funding away from the GP sector would almost certainly threaten such goals.
7. Training and Education
Medical students these days are digital natives who grew up with technological developments and societal relationships to technology not contemplated much or at all by our current education and training curriculums.
They will be moving into a medical world with far more technologically aware and educated patients and in which technologies like AI (especially AI I suspect) and the cloud are going to play a huge part not just in how they manage their patients, but, for those that choose to go down that path, how they manage their medical businesses and the relationship that these private entities end up having with patients.
For generations now, when big drug companies are developing a major new drug class, they will often start seeding the education around that drug class into university medical curriculums, often many years before the drug is even due for regulatory approval. That’s foresight.
Education and training for most doctors and GPs remains heavily clinically focussed with still little forethought to the technological, business and societal challenges that GPs are now facing moving into the workforce.
The RACGP and ACRRM general practice training programs remain more or less hard-wired for GPs to follow a traditional path into a bricks and mortar rural or city medical practice and don’t contemplate a lot of these fundamental changes.
Continuing professional development (CPD), which should address some of these changes to GP work life after the fact, tend to perpetuate these traditional models of thinking around education and training, so far at least.
How does a GP today learn how to use AI safely and effectively? As things stand, they usually have to rely heavily on the software vendor for their training and advice, which isn’t an ideal scenario. It’s like only having the drug company to educate you about a new drug.
The variety on offer for what GPs can do these days, in what ways they are able to work and who they work for is changing rapidly. The government is planning for GPs to be part of a connected integrated community care paradigm, with a lot of virtual care in the mix, a lot of which will be hubbed in new technologies, but the education and training curriculum remains stuck in an 80s-style learning and training curriculum.
Education and training and then the ongoing CPD aren’t currently meeting the needs of where the GP profession is heading and isn’t preparing GPs properly for the challenges of a workforce which will be spread a lot more thin, is a lot more eclectic and stressed, is reliant on a lot more technology for productivity, and is significantly part time.
8. AI
AI is going to massively change the way GPs operate and interact with their patients, hence some of the missives around education, training and CPD in listicle No 7.
Don’t worry, AI won’t be replacing GPs… at least those ones that are using it. They will float up on it largely, and likely have more time for more important clinical thinking, and most importantly, to spend more face to face time with patients.
So far we are at only at the very beginning of an AI productivity curve, with AI scribes.
It is estimated that depending on the nature of their clinical role, GPs will spend between one and half and three hours per day on non-clinical tasks.
As early as AI is into the picture, major AI scribes such as Heidi and Lyrebird, say they can save up to 90% of the time taken to take and summarise notes. How much time does that take you during a typical day?
A typical AI scribe will listen to your conversation with a patient, turn those words into text, and then generate a set of clinical notes, from which you can create referrals, summaries, certificates and certain reports. These systems will typically learn your style and get smarter in generating notes in your style over time.
This week, Lyrebird announced its first foray past basic AI scribe and note summary functions and into assisting the GP deeper into the optimising of patient outcomes game by reaching into the analytics integration Cubiko and automatically prompting a GP with suggestions for care plans for selected patients, and the appropriate use of MBS items in putting together such a plan so your billing is optimised as well.
The new admin help also suggests it will be able to optimise patient lists for a GP in queueing their patients and prepopulate relevant information about a patient that a GP is about to see.
All of these AI assisted functions require a doctor to view and approve after generation. In the case of potential care plan suggestions, and MBS coding alignment, its all prompts only at this point of time for a GP to use or not.
These new admin functions are likely to be initially controversial as people get comfortable with the idea that AI is safely and efficiently going to be good at looking at various pieces of patient and financial data in a patient management system and use related integrations to create appropriate on the fly analytics that will make a doctors admin work go a lot faster during the day.
For the naysayers, AI scribing has caught on fire across the world. It is rapidly becoming imbedded in a lot of medical workflows, with so far no meaningful incidents of dysfunction or patient harm.
That’s not to say that there won’t be problems. Things will go wrong almost certainly at some point on an AI journey, but odds are any dramas will come from human misuse, in particular coming to rely on their AI without appropriate review or oversight.
Already hospitals are looking at things like using AI to replace humans with the laborious and often highly variable inputs of humans into the process of coding doctors’ notes for EMRs. This stands to create huge efficiencies for hospitals in the near term.
And there’s a lot of work already proceeding on just how far AI can help in clinical decision support, despite this being a strict no-go zone in terms of day to day use today.
AI is a game changing technology for medicine and in particular for GPs given their day-to-day workflow and patient load.
It’s one case, at least, of “things don’t change: we change” because you need to consciously decide to give it a go.
