Pearls and Irritations

John Dwyer

  • John Dwyer. The structural reform of Medicare rather than its funding is the real challenge.

    Part 1; The model of primary care we need for contemporary Australia.

    For months the federal government has been telling us that a mandatory co-payment for a visit to our GP was essential to afford the $19 billion we currently spend on Medicare each year and projected increases. There would be an added benefit in that the payment would send a price signal to remind Australians that such visits can no longer be free. Too many of us are visiting our doctors too often! Additional revenue would be generated by a seven-dollar co-payment for prescriptions, pathology and imaging. Given the above propositions it is confusing to say the least that our government now plans to put every penny raised by these co-payments into a medical research fund that should eventually be the largest such fund in the world. Perhaps Medicare spending is not so unsustainable after all. International evidence tells us that we should be spending more on Medicare funded services to reduce total health expenditure. How would this work?

    Medicare needs to evolve from a universal insurance entity that pays doctors bills to one that funds clinicians who will provide a specific model of care. An uncapped payment of doctors “fees for service” not tied to any health outcome measures is not a satisfactory way to use taxpayers health dollars. World wide the move is to achieve better health outcomes more cost effectively by focusing on delivering  “Integrated Primary Care” (IPC) available from a person’s “Medical Home”.

    In our doctor centric health system, Australians visit their GP when they have a problem. They do this, on average, seven times a year. Many should go far more often to improve their health and many who need care the most visit their doctor infrequently. The burden associated with chronic and complex and often-incurable disease, compromises the quality of life for too many Australians, dominates the care requirements of many GP practices and cost us all a fortune. Given that so much of this suffering is preventable why is their so little emphasis on prevention and the provision of the health infrastructure to facilitate prevention? Only 2% of the annual $180 billion health spend in Australia involves prevention.

    At the other end of the care spectrum our Primary Care system lacks the infrastructure to care for many in the community and thus avoid the need for hospital care. We have more inpatient “overnight” beds per capita than any other OECD country and yet at the moment we need more. We hear almost daily about access problems for patients stuck in Emergency Departments because there is “no room in the Inn”. What our government does not seem to appreciate is that annually some 600,000 of these admissions (cost $ 30 billion) could be avoided with an effective community intervention in the three weeks before eventual hospital admission. The University of Melbourne studied this matter and found that each year seven million bed days are consumed by avoidable hospital admissions. We spend more than $140 billion on public hospital care each year, seven times more than we spend on Medicare. If we had one level of government funding health care instead of our destructive jurisdictional division of government responsibilities (States for hospitals; Canberra for Primary Care) we would readily spend more on Primary Care models that would reduce the need for so many hospital beds.

    The preferred model of IPC involves establishing a practice (Medical Home) populated my clinical teams, (doctors, nurses, allied health professionals a dentist etc) in which patients enrol with the understanding that they and the team share the responsibility for keeping them well and providing the best possible care when they are ill. The psychology of enrolment is all-important as is the principle that the most suitable members of the team will care for one’s current specific needs. Health maintenance is regarded as an active endeavour. This is evidence-based personalised care. Health literacy and lifestyle analysis, and support for needed changes, might be facilitated by specialised nurses and nutrition experts. Continuity of care improves the chance of early diagnosis and treatment of problems that could become chronic (early signs of adolescent mental health issues for example).

    Team management of chronic conditions with a team based case manager and care for fragile members of the practice in the community by appropriate clinicians to reduce the incidence of hospitalisation are also important initiatives. There is one medical record and rapid access to team members is facilitated by IT connectivity.  Well-established IPC units in other countries have reported up to a 42% reduction in the need for hospital care. Such a model makes best use of the unique skill set different health professionals possess, so different from our current “silo” mentality that makes the integration of an individual’s care so difficult. So successful is this model that already universities around the world are concentrating on moving to inter-professional learning curricula, “Team learning to prepare for team practice”.

    This is “Managed Care”, a term that conjures up in the mind discredited model of care available in the US. There are three players making decisions in much of the US system, the patient, the care team and the patient’s insurer. The latter, famously documented in Michael Moore’s documentary on the issue, all too often interfere with care plans even vetoing them on grounds of affordability. We need to think carefully about the wisdom or otherwise of allowing our private health insurance industry (PHI) to cover members primary care expenses. I would be less worried about interference in care plans here than in the likely creation of a “two tiered” primary care system in which those who can afford PHI would enjoy much better primary care than those who could not. The resulting furtherance in the inequity palpable in our current system would not only be un-Australian but expensive.

    Part 2 of this series will be posted tomorrow. It covers the necessary changes in the health workforce. 

    John Dwyer is the Emeritus Professor of Medicine at UNSW.

     

  • John Dwyer. Primary healthcare in Australia reaches the crossroads.

     When I graduated some 50 years ago more than 50% of my class pursued careers as General Practitioners. In the last available survey of the career intentions of graduating medical students only 13% said they were interested in Primary Care and only 13% of those who would consider a career in rural Australia. Currently more than 45% of the General Practitioners available to rural based Australians are overseas trained doctors most of whom are working there as provider numbers were not available for metropolitan practice. The average age of working General Practitioners is 55 years.

    Young doctors considering vocational training cite positive and negative reasons for their disinterest in Primary Care. Many other career opportunities seem more attractive as they provide much higher average incomes and part time employment provides funds sufficient for many. General Practice training is equally as vigorous as that required for other specialities but “GPs” are not paid as specialists and often feel their vital and increasingly unique skills are underappreciated. Tales from GP land tell young graduates of practice subjected to stifling bureaucracy, the need to “bulk bill” and thus to practice “turnstile medicine” with short consultation times being unsatisfactory to both patient and physician. These and many other impediments place us in real danger of having far too few GPs to provide us with quality Primary Care in the near future.

    All this reality is addressed by rhetoric from government reassuring GPs that they are the “heart and soul” of the nation’s health care system. The fact that the Federal government is freezing cost of living adjustments to Medicare rebates for four years and considering strategies to reduce our 18 billion dollar annual Medicare expenditure should not be taken personally. As I have commented here previously, we should be spending more not less on Primary Care but Primary Care that is restructured to better meet contemporary needs. This would include reducing the seven million bed days utilised in public hospitals by avoidable admissions. Hospital expenditure dwarfs Medicare spending.

    Is it possible that the introduction of a new model of Primary Care could produce better, more cost effective health outcomes for Australians and at the same time attract a new generation of doctors to Primary Care? International experience would say the answer to both questions is a definite yes. We know what that new model should provide; infrastructure to support preventative strategies, early diagnosis of problems that, left untreated, could become chronic, team management of established chronic and complex diseases and care in the community for many who are currently being sent to hospital. The model described is usually referred to as “Integrated Primary Care”  (IPC) which, to use American parlance, provides individuals with a “Medical Home”.

    IPC is structured around teams of health professionals working in the one practice. It is not doctor centric and provides individuals who enrolled in the IPC program with access to doctors, nurses and a range of allied health professionals including dental hygienists. Doctors cannot provide all the services described above but here can concentrate on those things only doctors can do. Well run IPC programs in the UK, the US, New Zealand and many other countries have demonstrated their cost effectiveness, better health outcomes and fewer admissions to hospitals for the patients of such medical homes. Perhaps most importantly in our context, they attract and hold GPs who enjoy better job satisfaction in this form of practice. An international trend has IPC practices offering their doctors flexible arrangements for remuneration. Rapidly payments based on a “fee for service” (FFS) are giving way to “blended payment” options. What is this all about?

    Many Australian GPs want to move away from the FFS model with very significant numbers joining large corporation owned practices where they are salaried or paid on contract. FFS at bulk billing rates does not work well for patients with chronic diseases and complex needs. A number of countries are offering their GPs fixed annual payments for their care of complex patients while those seeking a “one off” service are still charged a fee. In New Zealand more than 85% of the GPs work in such a system with about 80% of their income fixed with the remaining 20% coming from traditional FFS payments. Such arrangements are in the medical news here in Australia as Minister Dutton has publically expressed cautious interest in seeing how this could work in Oz. In the US 60%of GPs are paid in this way and this is increasingly so in the UK. There is an abundance of data showing that blended payments within the IPC model produces better health outcomes with fewer hospital admissions.

    Overseas experience with this radical reform tells us that its implementation must be a “bottom up” one available to willing participants and never forced on the medical profession. Space doesn’t permit detailed discussion of the mechanisms involved in establishing this system but if we were to follow say the NZ model it would look something like this. Our Medical Locals would become Primary Health Care organisations and holders and distributors of a primary care budget provided after careful analysis of local needs. GPs or IPC practices would negotiate for a fixed payment for their care of their patients with chronic diseases and in return would provide quality/outcome data associated with the use of that money. Financial incentives are built into the contract to encourage “best practice” management.

    Our medical profession, government and citizenry, should not be concerned by the exploration of these changes. The evidence is strong that, done properly, the results are very positive and the model attractive to clinicians and patients alike.

    John Dwyer is the Emeritus Professor of Medicine at the University of NSW.

  • John Dwyer. Cutting waste and costs in health.

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    Tactics and strategies for a six year journey to sustainable, equitable excellence

    (1) Move to a single funder for our national health scheme (The Commonwealth). The funder would contract with States and other potential providers to deliver integrated patient focused care. The health bureaucracy would be reduced by 80% with greater efficiency, better outcomes and less duplication saving at least $ 4 billion per year.
    (2) Remove Tax-payer support for Private Health insurance. Health Insurers are making large profits. Australians will retain their PHI as other sticks make that a certainty. The introduction of the subsidy saw PHI increase by only 2%.
    (3) Introduce peer and craft approved critical pathways to see more evidence based decision making re tests and procedures . Savings $20 billion per year.
    (4) Focus on reducing avoidable expensive hospital admissions ( more than 600,000 per year) through cheaper and better timely community interventions. Requires the introduction of Integrated Primary Care teams. Will need to broaden Medicare funding to cover health professionals other than doctors but net savings anticipated at least $7 billon per year.(5) Introduce slowly but steadily capitated funding for the management of”chronic and complex”diseases with mandatory reporting of health outcomes.

    Professor John Dwyer is Emeritus Professor of Medicine at the University of New South Wales.

  • The mooted $6 fee for GP visits trivialises the problem. Guest blogger: John Dwyer

    There is a lot that is disturbing about the federal government’s flirtation with a $6 co-payment for a service from a GP. Most commentators have rejected this approach as poor public policy as it will act as a deterrent for poorer Australians to seek the care they need to provide paltry savings in a 120 billion dollar a year health system. This policy will cost all of us dearly as avoidable chronic illness among those less economically secure already absorbs so many of our tax dollars. With the exception of illness caused by excessive alcohol consumption, all risk factors for serious disease are more prevalent in less advantaged Australians. Studies show that already too many patients delay seeking help and fail to take prescribed medications because of the costs involved. Health care in our wealthy country is distressingly and increasingly inequitable.

    However the major frustration with the current debate is associated with the lack of political understanding of the changes we do need to make to provide better health outcomes from a system that is financially sustainable. Cost effectiveness can only be tackled with a whole of system analysis not just a focus on the federally funded Medicare program that supports our delivery of primary care.

    The compartmentalisation represented by Minister Dutton’s focus on the cost of Medicare is the price we pay for the wretched jurisdictional separation of funding arrangements for Hospital and Primary Care services in Australia, the only OECD country so burdened.  Hospital expenditure dwarfs primary care expenditure so looking at the cost of funding Medicare divorced from a system wide analysis of health care costs is nonsensical.  In the actual health care delivery world the success or otherwise of our Medicare funded primary care system has a major influence on how much we need to spend on hospital care. Indeed the pertinent truth is that hospital funding into the future will only be manageable if a modernised and remodelled primary care system can reduce the demand for hospital admissions.

    We need and want a national health care system characterised by its resourcing of evidence based strategies that prevent avoidable illness and the provision, in a timely manner to those who are ill, cost effective quality care available on the basis of need and not personal financial wellbeing. These are not Utopian goals but their delivery will require additional spending in a number of areas. However there are major savings that can be made in our current system that would fund a remodelled health system.  For example, nine departments of health to service 23 million people are not only cost ineffective ($4 billion a year in duplication costs) but also makes proper integration of services impossible. 30 years of working closely with State and Federal health bureaucrats has taught me that the system sees good people more concerned about saving dollars in their patch and maintaining their power base than providing patient focussed integrated care. We need the Commonwealth to be the single funder for our public health system contracting with providers to deliver the integrated system describe above.

    Remodelled Primary Care with the infrastructure for the support of prevention programs is the most important initiative we need to implement in Australia. Around the world the trend is to establish primary care systems that encourage citizens to enrol in a wellness maintenance program and benefit from the delivery of health care by teams of health professionals working as “first among equals” in the one practice (Integrated Primary Care” (IPC). The psychology associated with voluntary enrolment is important .The philosophy involves acceptance of the concept that we need to take more responsibility for our own health but with personalised and ongoing assistance, when necessary, from appropriate health professionals. 85% of our New Zealand cousins are voluntarily enrolled in a “Primary Healthcare Organisation”.

    The Productivity Commission reports that between 600,000 and 750,000 public hospital admissions could be avoided annually with an effective community intervention in the three weeks prior to hospitalisation. An average hospital admission costs at least $5000 while a community intervention to prevent that admission would cost about $300. Primary Care infrastructure in Australia needs to resource the needed community interventions. The savings would more than cover the expense of introducing Integrated Primary Care into Australia.

    The introduction of IPC in Australia is likely to attract more medical graduates into a career as a GP.  Research tells us that only 13% of medical graduates in Australia plan a career in Primary Care. Remuneration is poor compared to other specialities.The need to bulk bill puts time constraints on episodes of care resulting all too often in “turnstile medicine “which is unsatisfactory for both doctor and patient. A young graduate will not be impressed with the Abbott government’s decision to cap Medicare payments to doctors for four years. Many younger doctors considering general practice would prefer to move away from the traditional “fee for service” payment system to salaried or contractual payments. Watching the journey that is leading to IPC in other countries can teach us a lot. In New Zealand over 85% of GPs have voluntarily forsaken “fee for service” payments in favour of guaranteed remuneration in a capitation model.

    The Abbott Government should commit to taking us on a health reform journey that embraces the above changes and the introduction of a single funder for our health system. To be talking about $6 is to trivialise a major policy challenge.

    Professor John Dwyer is the Emeritus Profess of Medicine at the University of NSW.

     

  • No vision for the health system we need. Guest blogger Prof. John Dwyer

    In this election the Coalition has provided dollar promises for worthy projects but no new health policy initiatives while only two of note have been forthcoming from the government; a long-term investment in stem cell research and the threat to remove family tax benefits from parents who put their children and the community at risk by not immunising them. Both are laudable but of greater interest to Australians would be our politician’s plans for solving the many problems that compromise the delivery of sustainable quality health care in our country. In a   recent survey “Research Australia” found that funding for health and medical research is a higher priority for Australians than immigration policy and border control.

    The current government has not focused on health system reform but rather reform of hospital financial arrangements with the States reinforcing the inappropriate hospital centric priorities of our health system. In reality financially sustainable quality hospital services are dependent on policies that will reduce the demand for those services. This will require real system reform. The National Press Club debate with Tanya Plibersek and Peter Dutton found them in furious agreement on most issues such as hospital funding, the importance of medical research and the need to emphasise prevention.  One was left with the impression that whoever wins the election it will be “business as usual” for our health system. That’s disappointing.

    Healthcare in Australia is beset with structural inefficiencies, inappropriate models of care for our times and cost increases that are producing major inequities that deny many the care they need and are promised by Medicare. This is particularly obvious in rural communities. Their problems did not get a mention in the debate. The major barriers to real change remain the opposition from those with vested interests in maintaining the status quo and the lack of political leadership to take us on a necessarily long (ten years or more) reform journey that doesn’t sit comfortably within current short election cycles.  If we take that journey its important to have a clear vision of what an appropriately reformed healthcare system should look like?

    Australia 2023. The Commonwealth has become the single funder of our public health system. An independent statutory authority has been established to fund a number of “Regional Health Authorities” (RHAs) charged with delivering the model of care the Commonwealth (Australian people) have embraced. It is described thus; Our health care system should be characterised by its resourcing of strategies to prevent avoidable illness and provide in a timely manner to those who are ill, cost effective quality care based on an individuals need not personal financial well being.

    These RHAs are funded on a per capita and local needs basis. No longer are state boarders a barrier to efficient health care. RHAs contract with a series of providers in their region to supply patient focused integrated hospital, community and primary care services. Quality and safety data are collected and published.

    A new model of primary care has been established with a strong focus on disease prevention. Australians are encouraged to enrol in a primary health care practice. Enrolment is significant in that it signals the creation of a partnership and shared responsibilities between patient and the practice’s health professionals.

    In the new model, primary care practices work under the umbrella of Primary Health Care Organisations (PHO). These support local GP led services wherein teams of RHA funded health professionals from a variety of disciplines work collaboratively to deliver a range of services to enrolled patients. (“Integrated Primary Care”) No longer do people only visit a medical practice when they are ill, they attend to work with appropriate health professionals to help themselves and their families stay well.  There is no more efficient use of health care dollars that ensuring that children get a healthy start to life. An obese 4-year-old child is very likely to be an obese adult. Continuity of care provides us with the best chance to detect early signs of mental illness when serious problems can still be avoided. Such team-based practices are not doctor centric. Nurses and allied health professionals deliver much of the prevention program. Most doctors dissatisfied with the “turnstile medicine” approach fostered by “fee for service” payments have accepted the opportunity for payment by contract with an RHA. GPs who, after all, are highly trained specialists but were not previously paid as such, are financially much better rewarded in this system. This, plus the attractiveness of working in the team environment, is attracting more medical graduates to primary care, in 2013 very few medical graduates were interested in such careers.

    Unlike the “old fashioned” Medicare Locals of 2013, PHO’s act as central service providers for linked, local and clinically autonomous practices. They themselves offer clinical services including acute services that do not require the facilities of a hospital sparing local emergency departments from inappropriate attendances and provide associated practices with business skills, bulk purchasing, continuing education, the collection of outcome data (now a mandatory requirement), and IT services including help with the further development of now popular patient controlled electronic health records. Primary, community and hospital care provided to an individual is seamlessly integrated.

    Also important has been the major revision of clinical training in the nation’s universities. “Inter-professional learning” wherein students of Medicine, Nursing, Dentistry and the Allied Health professions spend time learning together has produced a mutual appreciation of the specific skills of each group and how combining these skills in the “Team Medicine” approach can be so much more satisfying for professionals and patients alike. How different from the professional “silo” mentality of a decade ago. Medical schools in rural based universities with programs focussed on educating students with a strong rural affiliation and a desire for a rural based career are seeing significant numbers of graduates helping rural Australians. We are, at last, becoming less dependent on overseas trained doctors, many of whom are badly needed “back home”. Medical education has been shortened without any damage to required learning and is much less focussed on hospital-based rotations with more student time spent in community settings. The old mandatory Internship program has been abandoned in favour of immediate post graduation entry into vocational training programs.

    State governments are no longer receiving Commonwealth funds to run their hospitals but they do continue to own and operate them.  Funding required is supplied through a contract with a Regional Health Authority. The services to be offered by a particular hospital will be negotiated with emphasis on the quality rather than the number of services on offer. “Role delineation” for all hospitals within a given region will avoid duplication and avoid the old system where individual hospitals tended to be islands in an ocean of health care doing there own thing. Many private hospitals offer services to RHAs

    Back to August 2013.

    Given health care is one of the top three issues of concern for Australian voters, it’s disappointing that health system reform has so far received so little attention in the election campaign.

    We could reasonably expect our politicians in the last week of the election campaign to be seriously challenged to provide a detailed and clear vision of the health reforms they would pursue to create a more equitable and cost-effective health system that will met our future needs.

    But we will almost certainly not get this. And perhaps that says as much about the demise of decent journalism as it does about our politicians.

    This article was first published in The Conversation on August 30, 2013.

     

  • Health care reform remains a prisoner of Federalism. Guest blogger: John Dwyer

    The intractable problem that sees a very wealthy country unable to provide cost effective and equitable health care is a political one. We are the only OECD country in which the provision of health care is illogically and inefficiently divided between two levels of Government. The Federal government is charged with funding, but not providing, Primary and Community care. The State governments are both funders and providers of our public hospital system and endless arguments (“the blame game”) revolve around the adequacy or otherwise of the contribution to hospital care from the Commonwealth. So 22 million people are served by nine departments of health with duplication costing us about $4 billion a year!

    Our Health system is sickness and hospital centric and unlike much of the rest of the world we have not changed our Primary care system to provide Australians with a care model that focuses on prevention. Such a system provides the “Win Win” situation where Australians would be healthier and the demand for hospital services would be reduced. The Productivity Commission reports that each year 700.000 admissions to public hospitals could be avoided by an appropriate community intervention! The States cannot pull the leavers to improve Primary Care and so relieve pressures on their hospitals and the Commonwealth seemingly does not know how to do it. The Federal government has no experience in delivering health care.  At this time when health care should be patient focussed with the spectrum of care from the doctor’s office to the hospital totally integrated (seamless) how frustrating is it that COAG has actually enshrined the separation of Primary and Community care from Hospital care?

    It’s an election year and we should again be pressuring our politicians to embrace the only solution to all this inefficiency and inequity. The Commonwealth should be the single funder of health, providing our health dollars to a single agency with appropriate expertise that would contract with various providers to deliver the required integrated system characterised by the features described above. John Menadue’s suggestion for a trial of a similar approach at State level where an agency with pooled Commonwealth and State money delivers integrated cost effective health care makes sense but even this, perhaps less difficult option politically, currently has no traction around the COAG table. The Australian public would have applauded Kevin Rudd proceeding along these lines. That same Australian public must keep such health reform strategies on the election year agenda.

    John Dwyer