17 July 2019

The PIP for Aboriginal patients has its own gaps

KnowCents Medicare RACGP

The incentive scheme for general practices could help close the health gap by engaging more Indigenous patients in primary care, but only if it is better funded and its administrative flaws fixed, says the RACGP.

In a submission to the Health Department on the review of the Practice Incentive Program – Indigenous Health Incentive, the RACGP says the PIP-IHI is an alternate funding stream to the Medicare Benefits Schedule that is particularly important to Aboriginal Community Controlled Health Services and other practices with large numbers of Aboriginal patients.

But it is administratively clunky, payment numbers are low, it fails to allow for patient mobility, and more could be done to ensure cultural safety.

Currently under the PIP-IHI, practices receive a payment to register an ATSI patient once a year and further payments for completing and reviewing a GP management plan, and for providing the majority of the patient’s Medicare-rebatable services. Patients must be over 15 years and have an existing chronic disease.

“The principles are a nice way to coordinate care for Aboriginal patients, which is needed,” Dr Tim Senior, from the RACGP’s Aboriginal and Torres Strait Islander Health Faculty Council, told The Medical Republic.

“We know that Aboriginal patients tend to have longer consultations, which means practices generate less Medicare revenue for seeing more complex patients – that’s a perverse incentive in the system.”

But there should be a one-off registration procedure, he said, rather than an annual one, which is bureaucratic and burdensome. And the payment system is weighted towards registration rather than follow-up, which is reflected in the “surprisingly low” numbers of Tier 1 and 2 payments.

“The funding is loaded on to patient registration, so we see lots of patients getting registered but the follow-up payments don’t get made, and it’s the follow-up that’s going to get care and outcomes improved,” Dr Senior said.

“Switching that incentive to be on their ongoing follow-up is an improvement we think would be relatively simple.”

He said Aboriginal patients tended to have higher mobility than the rest of the population, and currently the system only permitted registration with one practice at a time.

“We’d like to see a mechanism that recognises patient mobility so they can be registered with more than one practice and the practices can coordinate the care between them,” Dr Senior said, acknowledging a slight tension with the desire for a one-off registration procedure.

“We’re not quite sure how it would look, but it would be something that doesn’t pit practices against each other but encourages them to coordinate. Currently there’s a tendency for some poaching of patients for registration payments – that’s another reason for incentivising follow-up, rather than registration, payments.”

Then there’s the linking of the PIP with the Closing the Gap (CTG) PBS co-payment, a popular initiative that gives patients cheaper medications. Since the eligibility criteria are different from the PIP – the CTG is open to Indigenous people of any age with a risk factor for a chronic disease – and the benefits are to the patient rather than the practice, it makes little sense to link them.

“It’s messy,” Dr Senior said. “A 13-year-old with asthma would be eligible for the CTG but not the PIP; so would a 36-year-old who is a smoker but has no chronic disease yet. It gets complex when you’re trying to work through this with a patient who’s come to you for something else.

“And the CTG is a benefit to the patient, it makes their meds cheaper, but the PIP is a benefit to the practice. So a lot of us would like to see those decoupled. Registration for CTG should be linked to the patient’s Medicare number.”

He said engaging more Indigenous patients in primary care was the best way to close the gap in health outcomes, and cites the “paradox of primary care”: while specialists may provide higher-quality care for specific diseases, primary care achieves better overall health outcomes at the individual and population levels.

“The international and Australian evidence is really clear that primary care is where investment is needed to improve the health of a community,” he said. “People like to go locally and to be at a service where they feel comfortable and have a relationship with the staff.

“People come in with absolutely anything – anxieties, symptoms or planned care around chronic disease – so they’re really family and community centres rather than disease centres. That way you integrate care better than if it’s just programs around individual diseases.”

The RACGP submission says that while the consultation paper uses the terms cultural awareness, cultural competence and cultural safety interchangeably, they are distinct issues.

Dr Senior said cultural awareness was simply knowledge of cultural differences; cultural competency meant having a set of demonstrable skills that could be assessed, which were not universal but were specific to each community.

Cultural safety was a feature of a practice, not a doctor, and was judged by patients and the community.

“Having culturally aware or competent people in a practice doesn’t automatically translate to cultural safety. It’s about whether the whole environment welcomes someone else’s culture.

“In general practice we’ve become aware of the importance of posters and paintings and flags in the waiting room, which shows that you’ve thought about it. But it’s also about the way people are treated at the desk and assumptions not being made about them and some flexibility in responding to people’s needs. It also includes the individual’s consultation and communication skills.

“The evidence on training individual practitioners to achieve cultural safety is pretty weak: it’s probably necessary but not sufficient. You also need an organisational commitment, you need Aboriginal staff, it needs to come from management.

“And it’s judged by users, by patients saying: I feel comfortable here.”

He said many Aboriginal and Torres Strait Islander patients wanted this part of their identity acknowledged, and that as long as a GP’s attitude was respectful and interested, there was no need to worry about potential faux pas.

“You could ask, what’s your traditional country, or what footy team do you support? That can open up a whole discussion.”

It was much worse to rely on unspoken health stereotypes, such as smoking or overcrowded housing, without explicitly asking about a patient’s context.

The original requirement for a practice to be eligible for the PIP-IHI was that one GP and one of the practice staff had done cultural awareness training, but there were no ongoing requirements. The college recommends training be more widespread and updated each triennium. Training is currently available through the college online and through Aboriginal Medical Services in partnership with Primary Health Networks.

Finally, Dr Senior said, the scheme could certainly use more money.

“Medicare funding for Indigenous people is at just less than parity with non-Indigenous people for primary care and much less for specialist care. You’d expect more Medicare funding to go to where there’s higher need. So the actual funding according to need is a lot less than it should be,” he said.