3 April 2019

Budget moves a start, but so much more is needed

General Practice TheHill

The federal budget and Labor’s budget reply have made significant investments in health, but left general practice advocates with many demands unfulfilled ahead of the election.

The Medicare rebate freeze is over, with both major parties promising that all remaining general practice items will be reindexed.

The Coalition government has committed to a new fee model for chronic care patients, while Labor has promised an extra $2.3 billion for Medicare, but dedicated the spending exclusively to cancer.

Treasurer Josh Frydenburg’s budget allocates $187 million over four years for reindexing, part of a $1.1 billion commitment to primary care that also includes $448.5 million over three years for a chronic disease funding model. This will reimburse general practices in quarterly payments for each enrolled patient, supplementing fee for service and supporting non-face-to-face care.

It leaves the Aged Care Access Incentive payment scheme intact, reversing a plan to axe it in August.

And, in a measure already announced, the budget sets aside $62 million for a rural generalist training pathway to help fix the shortage of doctors in the country.

The AMA and RACGP welcomed the budget measures as far as they went, but said they left plenty to lobby in the roughly six weeks before the expected mid-May election.

“Overall the budget does nothing to repair the damage that’s been done to general practice over the last 10 years by successive governments, so we’re still going to be looking for commitments during the election campaign to support general practice,” RACGP president Harry Nespolon told The Medical Republic.

“We’re certainly pleased that the flexible models of care came in. But it’s not a lot of money when you look at it over five years. It’ll be interesting to see what the details are.

“We were pleasantly surprised at the ending of the indexation [freeze] for all 176 items – once again it’s not a huge amount of money when you look at it over four years, $187 million. It’s good that money was allocated to the PIP Quality Incentive, the college has lobbied hard for changes to the program.”

He said the continued focus on investing in hospitals and tertiary care at the expense of primary care would be hard to shift.

“I point to what they’ve done in Denmark, which is cut the number of hospitals from, I think, 93 to 32 over 20 years, where they’ve decided that the best care patients get is in primary care. So it does actually happen and it can work. And it’s probably a cultural thing that we’re going to have to change over a long period of time.

“Eventually governments will realise that they just can’t build hospitals fast enough to deal with the medical care that patients need.”

Dr Nespolon cited mental health, where the Treasurer has committed $114 million for eight adult walk-in centres, as an example of the relative efficiency of general practice.

“While we’re always appreciative of money given to mental health, this is currently available in every public hospital in Australia, so you wonder why they’re doing this.

“If you gave that $114 million to me, I could probably build 50 general practices. We could get a much bigger footprint for the same money and it would be something that could offer these patients holistic care, which is what they need, not fragmented care.”

AMA president Tony Bartone told The Medical Republic he was pleased by the investment in general practice after years in the cold, but said this was just the start of a conversation ahead of the election.

“Overall, we thought it was a good, solid budget that sets up an election contest on health,” Dr Bartone said.

“After a long period of a lack of investment, lack of recognition of the importance of primary care and of general practice in the health system, we’ve had in excess of $1 billion in that general practice space between the budget and MYEFO.

“There were areas that weren’t covered, where we didn’t see enough, especially across public hospitals, and little if anything on prevention.”

The chronic care payments were, he said, the first step in revitalising general practice and recognising that while fee-for-service payments were the cornerstone of practice remuneration, they didn’t cover everything.

“It’s a reflection of the non-face-to-face work that we do, it’s a recognition of … the relationship between patient and practice. It was something we called for – coordination payments along the lines of the highly successful Coordinated Veterans Care [program], which has been applauded on both sides of politics and by all the major stakeholders.

“But this is the first step of a much more detailed, longer-term approach to revitalising and reinvigorating general practice by ensuring it can continue to deliver holistic care, keeping patients in better health and preventing unnecessary and unexpected readmissions to hospital.”

He welcomed the retention of the Aged Care Access Incentive, saying its loss would have been “a significant deterrent” to doctors making regular visits to aged care facilities.

But he said the mental health package, which also includes $263 million for more headspace centres and services and a focus on youth suicide, was “patchy at best”, with no overarching strategy or direction.

Indigenous health was “another place where we didn’t see enough investment, especially a clear path to Closing the Gap”.

The National Aboriginal Community Controlled Health Organisation, while it welcomed small allocations for suicide prevention and other specific initiatives, expressed disappointment at the lack of funding for Indigenous health overall.

The biggest item was $160 million for “Indigenous Health Futures” from the Medical Research Future Fund.

“We know that closing the gap will never be achieved until primary health care services are properly funded and our clinics have good infrastructure and are fit for purpose; until our people are living in safe and secure housing; until there are culturally safe and trusted early intervention services available for our children and their families; and until our psychological, social, emotional and spiritual needs are acknowledged and supported,” NACCHO CEO Pat Turner said.

Opposition leader Bill Shorten, in a move likely to resonate with large numbers of voters, announced what he called “the most important investment in Medicare” since its creation: $2.3 billion to relieve out-of-pocket costs for cancer patients, including $600 million for imaging and $433 million for the bulk billing of specialist consultations.

He said every MRI scan for cancer would be covered by Medicare, and also guaranteed to list on the PBS every drug recommended by “independent experts”, presumably the Pharmaceutical Benefits Advisory Committee.

Dr Nespolon said Labor’s response was yet another missed opportunity to invest in the most accessed form of healthcare.

“We have seen some signs that our political leaders are starting to recognise the vital role of general practice in our healthcare system, such as [the] promise to end the Medicare freeze. But unfortunately this recognition does not go far enough,” he said.

“This health policy fails the very people Labor seeks to represent.”

Until Medicare rebates were increased, patients would “still be paying more than ever for their healthcare”.

Dr Bartone said Labor’s investment would ease the financial burden on cancer patients and families and help them concentrate on treatment and recovery. But he hoped the opposition would be taking a broader health focus to the election.

“This is a great start, but we need to take a much more universal, whole-of-health view of the system that also looks at  primary care, mental health, Indigenous health, aged care, prevention, and other neglected parts of the system,” he said.

The centrepiece of the federal Greens’ health policy is Denticare. Leader Senator Richard di Natale, in a furious budget reply speech, made only fleeting references to health as he slammed the government for having no vision beyond tax cuts that would most benefit the wealthy.

“Middle- and low-income earners will pay for these tax cuts in crowded GP rooms and in hospital waiting rooms,” he said.

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