14 December 2016

The sorry state of primary-care health funding

General Practice Government TheHill

 

Life in general practice land sometimes feels like walking in the shadow of the “Valley of Hope”. The potential for what can be achieved through well-designed primary healthcare holds so much hope, yet primary-care health funding continues to be an area targeted as the “easy” option for cutbacks and “punitive” remunerative action.

We don’t have the major political clout of hospitals and pharmacists to persuade bureaucrats, and are treated like the “low value” kid in the medical fraternity.

I have lost count of the number of times I have been asked: “couldn’t you get into any other training scheme? (the implication being, you must be stupid)”, “Aren’t you bored?” or “Who would want to spend their day seeing the worried well?”

To make matters worse, many medical students seem to believe general practice is a speciality you only take up if you fail to get a place in a “real” training scheme. Or even more sadly, the economic realities of pay parity make general practice a no-go zone. After all, who wants to join a specialty that is referred to as #JustaGP!

Earlier this year I got very excited that maybe, just maybe, we had support for much needed change in our approach to primary care when the hot topic of Health Care Homes arose in March.

I was extremely positive about the announcement by Federal Health Minister Sussan Ley, that the government would fund a pilot project in response to the Primary Health Care Advisory Group report.

Over the past decade, I’ve been closely watching the literature around the emergent international evidence of the benefits of Patient Centred Medical Homes (PCMH) and the pivotal role of GPs in achieving better health outcomes.

The findings, from countries both similar and dissimilar to Australia, have been exciting – particularly with regards to the transformation of primary healthcare systems in places such as the United States. Finally, I hoped, we might also be looking forward to some exciting, well overdue health-system reforms in Australia.

As Atul Gawande says, “Making systems work is the great task of my generation of physicians and scientists. But I would go further and say that making systems work – whether in healthcare, education, climate change, making a pathway out of poverty – is the great task of our generation as a whole”.

And Paul Grundy, known as the “Godfather” of the Patient Centered Medical Home, says healthcare works best when most is done at the primary care level, with mortality reported as dropping by up to 19%. Specialist care without primary coordinated care is at the core of the majority of medical errors and complaints.

Further, investing in medical homes in Oregon in the US reduced flow-on costs of healthcare by $13 for every $1 invested in primary care. These are powerful and persuasive numbers.

Grundy also emphasises that how you pay matters. We should actually pay for what we want, and be strategic, he says. Denmark has achieved the delivery of 93% of all healthcare in the primary-care setting, with decreased overall costs and high levels of quality and safety.

They did this by remunerating medical services best done at the primary care level on a fee-for-service basis, but only for primary-care providers. Upstream service providers are not able to access these payments.

Incentives are also given to specialists to provide advice to GPs as a matter of priority, improving communication between all care providers and improving outcomes and the quality of healthcare.

Similar strategies would be worth piloting in Australia, and might even move us close to achieving the quadruple goal of primary healthcare, improved patient experience, improved health outcomes for the Australian community, decreased costs and improving the GP and primary healthcare team “joie de vivre”!

If we really want a Health Care Home, then we should be striving to be patient centred, comprehensive, coordinated, accessible and focused on quality and safety, and rewarding general practices for delivering quality care within the privatised business setting.

Dr Charlotte Hespe is a GP, practice owner, chair of CESPHN and head of general practice at UNDA, Sydney School of Medicine

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4 Comments on "The sorry state of primary-care health funding"

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Dr Lou Lewis
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Dr Lou Lewis
9 months 10 days ago
Dear DR CHARLOTTE HESPE, In your article you state ” Denmark has achieved the delivery of 93% of all healthcare in the primary-care setting, with decreased overall costs and high levels of quality and safety. They did this by remunerating medical services best done at the primary care level on a fee-for-service basis, but only for primary-care providers” , and by this I take the primary-care provider to mean the GP. As a solo GP i am a strong advocate of fee-for-service, yet everyone seems to poo-poo this model, which has been working successfully for me for nearly 40 years.… Read more »
Charlotte Hespe
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Charlotte Hespe
9 months 9 days ago
Hi Dr Lou Lewis, thanks for your observation. I am very supportive of patient centred care and see that if we really want to improve what we do we need to change some of our health system. I know that we all dislike change, and I do not want change for change sake.- but rather want change in order to improve what we can do for our patients and community. This may well mean different systems of payment – generally speaking you get what you pay for and so Fee for Service is very effective at delivering outputs. If we… Read more »
Frank Jones
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Frank Jones
9 months 10 days ago

Thanks Charlotte: great summary of all the evidence we know to be true: we must remain focussed on our patients’ best outcome and repeating these key messages at every opportunity with our patients, colleagues, key stakeholders and of course the politicians who lhear but don’t actually listen!

Oliver Frank
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Oliver Frank
9 months 10 days ago

Charlotte, thanks for this excellent summary of the situation and teh potential.

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