General Practice
Wiser health funding for better health
at lower costs
Future of Medicare Conference
Sydney Harbour Marrio...
Key Messages
• Medicare change won’t help if fundamental
health governance problems, waste, poor health
financing practice...
THE VIEW FROM GENERAL
PRACTICE
What are the key issues General Practice see contributing health funding
problems
“The reality is that there isn’t a single point
of leadership and accountability for health
care in Australia*”
“….the str...
Waste – in all shapes and sizes
Government
Federal Government
Technology savings not realised
– Pharmacy
– Surgical (catar...
Copayments … the mixed evidence
Instituted broadly …
• blunt instrument for
controlling costs
• Unfairly target poor
• spe...
Copayments … practical applications
• To reduce radiology
• To reduce pathology
• To reduce use of inefficient activity in...
Figure 1 ProductivityCommission – Report on Government Services
DoHA (Departmentof Health and Ageing) , MBS, PIP, GPII, DG...
Health Care is
increasingly
Hospital Centred
• Ambulances go straight to
Hospital (even minor conditions)
• Increasing A&E...
IHPA Payment Medicare for GP
Medical Consultations
Anaesthetics
Preanaesthetic assessment and evaluation - Specialist $291...
Comparing Hospital and GP payments
for same or similar services
(a) Independent Evaluation of the ACT Nurse-led Walk-in Ce...
Code Description Weight
$ per patient service event
(IPHA)
Allied Health
(MBS)
40.01Aboriginal and Torres Strait Islander ...
The view from General Practice
The problems of medicare are
not going to resolve if critical
flaws (other than finance
mod...
MEDICARE AND GENERAL PRACTICE
What's right and wrong now?
GENERAL PRACTICE HAS A
BLENDED FUNDING MODEL
General Practices - Practice Incentive Programme
Per Capita (SWPE)
• Infrastr...
Medicare -
Australian Government real
expenditure on GPs (2012-2013 dollars)
per person
*Fee for Service = $286 per year f...
Medicare -
Australian Government real
expenditure on GPs (2012-2013 dollars)
per person
*Add Radiology= $58.60 per year fo...
Medicare -
Australian Government real
expenditure on GPs (2012-2013 dollars)
per person
*Add Pathology= $58.60 per year fo...
Medicare -
Australian Government real
expenditure on GPs (2012-2013 dollars)
per person
Total GP Costs per day per person ...
How cheap is GP Care ...
Daily GP Costs Packet of Chips
$1.13 per day $1.45 per pkt
“Largely delivered by private practitioners, ….
the many community based services that could
help keep people well and out...
THE FUTURE FOR GENERAL
PRACTICE
If we want a high performance health system, what roles and functions of
General Practice ...
The fundamental paradox of primary care:
‘…a paradoxical situation: the tension between the
relative weakness and unattrac...
Palliative
Care
Complex
Patient Care
Active Chronic
Disease Management
Chronic Disease – Self Care
At high risk for Chroni...
GENERAL PRACTICE HAS A
BLENDED FUNDING MODEL
General Practices - Practice Incentive Programme
CHANGE
General Practices and...
Practice Incentive Programme for
General Practices
New Rationale - : To encourage General
Practices to organise the infras...
Traditional
GP Practice
“Niche” GP
Practice
Corporate
GP Practice
“Models” of General Practice are
changing
1Implement the Medical Home
Registration with 1 Doctor & 1
Practice
Delineates site/role of primary
care
Patient Registrat...
*
Delineate new roles for
General Practices –
then support them
New General Practice Characteristics
Advanced Multidiscipl...
Key Messages
• Medicare change won’t help if fundamental
health governance problems, waste, poor health
financing practice...
Evan Ackermann - Royal Australian College of General Practitioners National Standing Committee, Quality Care - Medicare Fu...
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Evan Ackermann - Royal Australian College of General Practitioners National Standing Committee, Quality Care - Medicare Funding of General Practice: Now and in the future

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Evan Ackermann delivered the presentation at the 2014 Future of Medicare Conference.

The Future of Medicare Conference was a timely event as the Abbott government debates a full over haul of the Australian healthcare system. This conference presented a chance for government representatives, regulators, health care providers in the public and private sector, educators and private investors to come together and debate the proposed changes to Medicare as well as discuss the best practice methods of implementing new measures and frameworks.

For more information about the event, please visit: http://bit.ly/FutureofMedicare2014

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Evan Ackermann - Royal Australian College of General Practitioners National Standing Committee, Quality Care - Medicare Funding of General Practice: Now and in the future

  1. 1. General Practice Wiser health funding for better health at lower costs Future of Medicare Conference Sydney Harbour Marriott
  2. 2. Key Messages • Medicare change won’t help if fundamental health governance problems, waste, poor health financing practices persist. • General Practice is cheap, but not funded to be effective to meet current & future challenges • A reinvestment in General Practice is required to make Australia’s health system more effective and efficient • A medical home and GP population health management as the basis of restructuring GP services and funding can optimise value
  3. 3. THE VIEW FROM GENERAL PRACTICE What are the key issues General Practice see contributing health funding problems
  4. 4. “The reality is that there isn’t a single point of leadership and accountability for health care in Australia*” “….the structural flaws in governance and financing make it difficult to develop, fund and co-ordinate the primary care, subacute care and specialist care in the community that would be better for people’s care*” …the failure to develop governance structures which promote the identification and resolution of problems according to their importance#. Suboptimal Health Governance in Australia • * Christine Bennett, ‘Are We There Yet? – A journey of health reform in Australia’ (Paper presented at the College of Medicine, Health Leadership Series 2013, The University of Notre Dame Australia, 18 March 2013) • # Jeff RJ Richardson Steering without navigation equipment: the lamentable state of Australian health policy reform Australia and New Zealand Health Policy 2009, 6:27
  5. 5. Waste – in all shapes and sizes Government Federal Government Technology savings not realised – Pharmacy – Surgical (cataract) Non-Evidence based health system interventions – Superclinics – After hours telephone services – ? PCEHR State Government Duplication / fragmentation Poor Efficient services (Hospital based primary care services) Not closing redundant hospitals Medical Overdiagnosis & Overtreatment – Disease definitions – Poor clinical guidance (gestational diabetes) – Cancer screening (prostate) – Radiology (++) – Protocol driven pathology Healthcare variation in care “Business of medicine” • Corporate models of health driving expenditure
  6. 6. Copayments … the mixed evidence Instituted broadly … • blunt instrument for controlling costs • Unfairly target poor • specifically reduce beneficial preventive care practice • Reduction in appropriate care not just unnecessary services Targeted … • Copayments may work where they are used to reduce demand for irrelevant, unnecessary, and inefficient health care • Reinvestment of savings make the universal healthcare system more effective care
  7. 7. Copayments … practical applications • To reduce radiology • To reduce pathology • To reduce use of inefficient activity in Public hospitals • Lifestyle choices – Smokers pay additional costs for vascular procedures – Limits on IVF procedures – Some Cosmetic procedures • To reduce inappropriate “health screening” • To reduce “futile care” – The relentless pursuit of marginal improvement • To reduce “low value” surgery • To optimise choice of medication – eg prefer old diabetes drugs v new – “alternate” medicines
  8. 8. Figure 1 ProductivityCommission – Report on Government Services DoHA (Departmentof Health and Ageing) , MBS, PIP, GPII, DGPP and DVA data collections; Where is the Problem ?
  9. 9. Health Care is increasingly Hospital Centred • Ambulances go straight to Hospital (even minor conditions) • Increasing A&E Department use – ?health direct hotline – Incentivised by 4 hour rule • Increasing Hospital Admission rates • Inpatient Care – Palliative Care, End of life care, Aged care, Multiple Morbidity • Change in Discharge arrangements • Funding Incentives – IHPA – Ambulatory care payments 2-6 times what they pay through MBS and have lower claims criteria *Australian Instituteof Health and Welfare 2013. Australian hospital statistics2011–12. Health services series no. 50. Cat. no. HSE 134. Canberra: AIHW # NationalEfficientPrice Determination2013-2014 IndependentHospital Pricing Authority Feb 2013
  10. 10. IHPA Payment Medicare for GP Medical Consultations Anaesthetics Preanaesthetic assessment and evaluation - Specialist $291 $36 /$72 Preanaesthetic assessment and evaluation - Nurse $293 Obstetrics Specialist Clinic $222 $36 Midwifery and Maternity $255 Alcohol and Other Drugs (Nurse) $156 $36 Sexual Health (Nurse / Allied Health) $185.48 $36 Minor Medical Procedures Venesection (Hospital) $438 $62 Dematology - Cons + Biopsies (skin Cancer) $305 20.33 Wound Management (Nurse - excludes complex wound management) $245 $36 Comparing Hospital and GP payments for same or similar services IPHA – Independent Hospital Pricing Authority
  11. 11. Comparing Hospital and GP payments for same or similar services (a) Independent Evaluation of the ACT Nurse-led Walk-in Centre 30th June 2011 b)Productivity Commission Report on Government Services Section E – Health Table 11.A2 & 11A.10 2103 Nurse Walk in Centre - Canberra Average cost per Service Av Cost for All GP Services $196 (a) $49.58 (b)
  12. 12. Code Description Weight $ per patient service event (IPHA) Allied Health (MBS) 40.01Aboriginal and Torres Strait Islander Health Clinic 0.0506 $249.61 $ 52.95 40.09Physiotherapy 0.0376 $185.48 $ 52.95 40.18Speech Pathology 0.0434 $214.09 $ 52.95 40.23Nutrition/Dietetics 0.0261 $128.75 $ 52.95 40.25Podiatry 0.0713 $351.72 $ 52.95 40.29Psychology 0.0577 $284.63 $ 52.95 Comparing Hospital and Allied Health payments for same or similar services IPHA – Independent Hospital Pricing Authority
  13. 13. The view from General Practice The problems of medicare are not going to resolve if critical flaws (other than finance models) are not addressed Similar funding arrangements to public sector • have an honest cῸnversation about health expenditure without political gaming Determine what is an Australian version of a high performance health system and GP Role
  14. 14. MEDICARE AND GENERAL PRACTICE What's right and wrong now?
  15. 15. GENERAL PRACTICE HAS A BLENDED FUNDING MODEL General Practices - Practice Incentive Programme Per Capita (SWPE) • Infrastructure eg (IT) / Nurses • Performance / Quality Incentive eg Diabetes Cx Screens • Services population ie ATSI General Practices and General Practitioners - Fee for Service • Medicare Benefits • DVA • Workcover • Private General Practitioners • Practice Incentive Programme • Skills (Rural -Anaesthetics, obstetrics, Surgery) • Aged care access • Other • Rural Incentive • Service Incentive Payments
  16. 16. Medicare - Australian Government real expenditure on GPs (2012-2013 dollars) per person *Fee for Service = $286 per year for every woman , transgender , man, and child $0.78 per day * ProductivityCommission – Report on GovernmentService DoHA (Departmentof Health and Ageing) , MBS, PIP, GPII, DGPP and DVA data collections; Chapter 11 Primaryand Community Care table 11A,2 GP Costs
  17. 17. Medicare - Australian Government real expenditure on GPs (2012-2013 dollars) per person *Add Radiology= $58.60 per year for every woman , transgender , man, and child $0.17 per day * ProductivityCommission – Report on GovernmentService table 11A.65 GP Costs Fees $0.78
  18. 18. Medicare - Australian Government real expenditure on GPs (2012-2013 dollars) per person *Add Pathology= $58.60 per year for every woman , transgender , man, and child $0.16 per day * ProductivityCommission – Report on GovernmentService table 11A.63 GP Costs Fees $0.78 Radiology $0.17
  19. 19. Medicare - Australian Government real expenditure on GPs (2012-2013 dollars) per person Total GP Costs per day per person to medicare $1.13 per day * ProductivityCommission – Report on GovernmentService table 11A.63 GP Costs Fees $0.78 Radiology $0.17 Pathology $0.16
  20. 20. How cheap is GP Care ... Daily GP Costs Packet of Chips $1.13 per day $1.45 per pkt
  21. 21. “Largely delivered by private practitioners, …. the many community based services that could help keep people well and out of hospital or provide a better and more cost effective care in a non-hospital environment are underdeveloped, underfunded and poorly co-ordinated.”* We argue strongly that strengthened primary health care services in the community should be the ‘first contact’ for providing care for most health needs of Australian people.. This builds upon the vital role of general practice. How effective is General Practice for today’s health care problems? * Christine Bennett, ‘Are We There Yet? – A journey of health reform in Australia’ (Paper presented at the College of Medicine, Health Leadership Series 2013, The University of Notre Dame Australia, 18 March 2013)
  22. 22. THE FUTURE FOR GENERAL PRACTICE If we want a high performance health system, what roles and functions of General Practice should be Medicare funded?
  23. 23. The fundamental paradox of primary care: ‘…a paradoxical situation: the tension between the relative weakness and unattractiveness of this level care versus the intention to assign critical strategic functions to it.’ From: Primary Care In the Driver’s Seat? Saltman, Rico and Boerma (eds) 2006
  24. 24. Palliative Care Complex Patient Care Active Chronic Disease Management Chronic Disease – Self Care At high risk for Chronic Disease Well Population
  25. 25. GENERAL PRACTICE HAS A BLENDED FUNDING MODEL General Practices - Practice Incentive Programme CHANGE General Practices and General Practitioners - Fee for Service • Medicare Benefits • DVA • MAINTAIN General Practitioners • CHANGE
  26. 26. Practice Incentive Programme for General Practices New Rationale - : To encourage General Practices to organise the infrastructure for appropriate and comprehensive primary care delivery that adds value to their local communities and the health sector
  27. 27. Traditional GP Practice “Niche” GP Practice Corporate GP Practice “Models” of General Practice are changing
  28. 28. 1Implement the Medical Home Registration with 1 Doctor & 1 Practice Delineates site/role of primary care Patient Registration will facilitate population Health activities
  29. 29. * Delineate new roles for General Practices – then support them New General Practice Characteristics Advanced Multidisciplinary health care teams Comprehensiveness of services to match local need Clinical governance Population management (Hospital avoidance) Health Service integration (?financed by states) Quality Management
  30. 30. Key Messages • Medicare change won’t help if fundamental health governance problems, waste, poor health financing practices persist. • General Practice is cheap, but not funded to be effective to meet current & future challenges • A reinvestment in General Practice is required to make Australia’s health system more effective and efficient • A medical home and GP population health management as the basis of restructuring GP services and funding can optimise value
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