We serve 83% of the population using 6% of the health budget, and we’re supposed to get more efficient?
I’ve been speaking at a few forums recently on how the health system is collapsing.
I’m often flanked by economists, who express considerable displeasure around the way “low-value care” is bankrupting the health system and often comment that you can’t fix the system by “throwing money at it”.
“We have to innovate,” they say: “doing the same thing with more money isn’t working.”
Hmmm. I doubt Winston Churchill facing the problems of World War II thought “throwing more soldiers” on to the Western Front was a waste of time, but I digress.
As one of the GPs involved in these conversations, I need some numbers to address the dominant narratives that justify bankrupting general practice. With the election coming up, I thought I’d share some responses to arguments that just won’t die.
1. We can’t keep doing the same things because throwing money at the problem isn’t working. We need INNOVATION. (So let’s pay GPs less.)
Well, we could try funding GPs properly, that’s never been tried.
At the moment, we are funded at $420 per year per patient, which is lower than Tony Abbott’s offering in 2015.
John Buckley made an awesome list of questions for innovators in last year’s RACGP keynote. One of his questions was “what does the innovation displace?”
For instance, if we look at one budget item, the “low-intensity digital mental health service”, which will use $111 million per year in federal taxpayer funding, this investment is roughly the same amount budgeted for the entire psychiatry workforce of NSW. And the National Survey of Mental Health and Wellbeing says less than 4% of Australians use digital services for their mental health anyway.
As one nice Canadian paper puts it, mental health digital products are limited in their uptake: “their promise is not fully realised because relatively little attention has been paid to whether and how consumers actually want them compared to the exorbitant amount of time, money, and labour that has been devoted to creating them. It is as if the self-help DMHI field has gone to great lengths and expense to throw a large party; venues have been booked, fancy cakes have been ordered, and entertainment has been scheduled, but nobody asked whether people can get to the venue, what food they want to or can eat, and what entertainment they like. Moreover, nobody collected RSVPs (Répondez s’il vous plaît). Is everyone going to show up?”
GPs currently “consume” 6% of the entire health budget, to see 83% of the population. Trying to make that more efficient is a bit sad, really. It’s like underpaying and overworking the intern to compensate for the salary of the CEO. How dumb would that be?
2. Anything digital is AWESOME, and anything non-digital is, well, old-fashioned and if not irrelevant, sort of uninteresting. (So let’s pay GPs less.)
Ah, technological glitter. It’s pervasive, it never works as it should, and for every bucket of glitter thrown at a problem, 75% of it seems to slide off to contaminate other things.
I am not a Luddite, and yes, I use scribes etc. BUT technology is seldom the answer to healthcare systemic failure.
Have you noticed that the more labour-saving devices we create for the home, the greater the expectations, and so the greater the domestic labour? Look at what I had to cook with in childhood: an egg beater, a wooden spoon, a set of scales and a bowl. Now look at Masterchef. Now you can’t produce a kid’s birthday cake without several tiers, a specialised blow torch and some unpronounceable ingredient. I’m not seeing time-saving in this endeavour.
Remember when we were told computerised practices would mean a paperless office and more time for patient care? The one thing I’ve learned through my long career is the greater the technology, the greater the administration requirements, chiefly in compliance, data-gathering and bureaucratic nonsense. It NEVER “frees me up” to spend more time with patients.
The evidence for this comment is low, but we all know it’s true. Think back to the accreditation requirements 20 years ago. See what I mean?
And the cost? Well, the digital health agency budget so far is around $2 billion. Admittedly, that’s less than the $3 billion offered in the Eighth Community Pharmacy agreement following the 60-day script announcements. But there IS another $1.2 BILLION going to update technology in aged care facilities. If only that enabled the provision of recognisable food.
3. We need to start paying GPs for OUTCOMES not inputs. (So let’s pay them less.)
Imagine the amount of time it would take to create a meaningful outcome measure for Mrs Jones, with her five chronic diseases, low literacy in English, social isolation, challenging kids, equally challenging (and dementing) parents, workplace bullying and opioid dependence for her chronic pain. Let’s say we had to develop an outcome for a consultation. The usual loooong consultation. Where would you start?
And wouldn’t that mean that GPs in practices with educated, literate, professional people with one illness who are able to generate and meet standardised outcome measures would “perform” better than the poor GP managing the complex needs of Mrs Jones? Thought so. Nothing like an exponential rise in privilege on all fronts.
Related
4. There’s FRAUD. (So let’s pay GPs less.)
Did you know that GPs collectively donate around $1.3 billion in unpaid labour a year? It feels like it, doesn’t it? And did you know once we even out overbilling and underbilling we subsidise the health system around $400 million a year? That sounds less like fraud and more like exploitation.
5. We need more DATA before we can justify changes to GP funding. (So … you get the idea)
Robodebt survivors should not have to pay for their healthcare by giving away their sensitive health data. It is in AHPRA’s code of practice that I keep my patient data confidential. Does this mean I shouldn’t be using an item number that records their reason for presenting (e.g. the proposed menopause item number)?
Coupling rebates to data collection – like the suggestion that the minister would “claw back” rebates if data was not entered in the MHR – is an outstanding overreach of government into my consulting room.
We are the most effective and efficient part of the health system. We save lives. This is an awesome bit of data, and hasn’t made one iota of difference to our funding. What data could possibly trump that?
6. Low-value care is costing the system MILLIONS so it needs to be eradicated to make the service efficient. (Pay ’em less until this is eliminated.)
Let’s look at low-value administration that causes harms. GPs average 8-10 hours a week in unpaid administrative tasks. If we could halve that, we could free up 26 MILLION consultations a year.
NDIS admin costs $3500 per patient per year, and that’s just the NDIA and the coordinating organisation. It doesn’t begin to take into account the amount of time spent by patients, carers, and people like me.
And as for My Aged Care, who thought a 10-digit number and an online form was a good idea in aged care?
Not everyone can read. I recently saw a father and son and asked them if they had Centrelink benefits.
“Nah,” said the Dad, “I tried, but they made me use a computer, so I left.”
I turned to the son: “What about you?”
“They gave me a form, and it was 26 pages, so I chucked it out.”
“How do you support yourselves, then?”
“We beg.”
No one should have to beg because they can’t fill in a form.
7. Today’s GPs aren’t like the old GPs. They just do short consultations with no continuity and don’t bulk bill. (So let’s pay them less until they DO AS THEY’RE TOLD.)
It is rarely understood that the rebate is optimised for six minutes. I think I tried this phrase at the last think tank: “Because that’s the length of consultation Medicare wants, that’s where they put the optimal rebate. Dumb, isn’t it? Patients want longer consults, and so do we.”
8. Nurses/allied health/pharmacy can do the same job for less money. (So let’s pay GPs less.)
Multidisciplinary teams are hardly news for GPs, we’ve been using them over our entire careers, they just aren’t always co-located. In fact, in the days when Edelstein set up the first bulk-billing clinic with its white grand piano and chandelier in Sydney, we were taught that it was unethical to require patients to use in-house services that benefit the bottom line of the corporates. Edelstein famously received free computers from the pathology companies he hosted on site.
I think the best examples of multidisciplinary teams are around single diseases, like cancer, or Aboriginal Medical Services. In the AMS, the decisions of how the practice is structured depends on the community, who control the structure and function of the clinic.
I’m happy to structure my practice appropriately if it is required by my patients, but not because it is decided that this structure is universally “good” by the federal government, the economists or the entrepreneurs. Different contexts drive different practice structures, as they should.
Besides which, I think patients should be able to choose their team if they want to, not be locked into the team I choose.
And in England? The data on effectiveness, efficiency and the ability of primary care multidisciplinary teams to keep ED numbers down is “mixed”.
Given we are spending $5.9 billion on Medicare reform, I’d want better evidence than that.
Associate Professor Louise Stone is a working GP who researches the social foundations of medicine in the ANU Medical School. She tweets @GPswampwarrior.
