While most agree the HCH concept is sound, the devil is in the payment detail
Nearly 200 general practices and Aboriginal community health services have taken a leap of faith in signing up for the government’s Health Care Homes trial for chronic and complex care.
In the time since the bundled-payment scheme was trumpeted in 2015 as a plan to revolutionise Medicare, it has been dogged by delay and negative publicity about possible GP tax liabilities, alleged inadequate funding, and corporate involvement.
Finally, a second group of 168 practices was announced in early December, following the October group of 22 early starters. Patient enrolment is under way, with a guideline of 55 patients per participating GP, though it is uncertain whether the trial will secure the target of 65,000 patients.
Practice manager Shabnam Ali, whose family business operates six practices in Brisbane, including four in the HCH trial, sees the initiative as both a learning opportunity and a chance to influence the direction of change in primary care.
“We felt (the trial) would be a good opportunity for us as a business to make some changes and for our clinicians to give feedback on what works, instead of doctors being unhappy (about change) and not able to feed anything back,” she said.
“Also, it sounds like shared-care planning is where everyone is going in this new age of healthcare.”
The 10 Primary Health Networks helping to coordinate the trial have been funded to employ “practice facilitators” who are on hand to answer questions and provide assistance with issues such as software.
The question no-one can answer, however, is whether this experimental shift from fee-for-service to bundled payments for GP clinics to coordinate the care needs of patients with chronic disease will be viable.
Adelaide GP Dr Sian Goodson said the mood at a recent information-sharing gathering organised by her PHN was one of cautious optimism.
“There has got to be an advantage for patients in better access to care and developing different was of delivering care,” Dr Goodson said.
“I’m just slightly unsure about the business model.”
Dr Walid Jammal, whose Sydney practice was an early adopter of the patient-centred medical home concept and was one of the October tranche of Health Care Homes, says he is convinced the trial poses no financial risk to GP clinics.
“Will the money be enough? I don’t know. Ask me in two years,” Dr Jammal said.
“But I do know that this is an absolutely wonderful thing for patients, and we are prepared to stick our necks out.”
Dr Jammal said the patient-centred approach drove positive changes, with GPs and practice staff coordinating a range of internal and external services to provide integrated care.
“It makes you think about the way you work and redesign the way you work, so it is better for patients,” he said.
“Two months in, patients are not hesitating to enrol.”
Ms Ali, the business manager, points out that viability will be a key aspect of feedback.
“I’m looking at this as if we were essentially doing an audit,” she said, drawing a comparison to a recent project with her PHN on auditing clinical performance on managing COPD.
“When you see the results in clinical care and in your revenue, you know you are doing something right. When those results are presented to the clinicians and the nurses, they are really motivated. They come up and say, wow, we are doing really well.”
Her approach will be to go slowly, targeting certain cohorts of conditions first.
“For us, it is not too different from what we already doing – involving everyone in the team in the care of the patient – but we may not take a one-size-fits-all approach across our practices.
“Their demographics are very different, so our approach will be tailored to whom we are looking after.”
One clear point of agreement shared by north Brisbane practices joining the trial was the need to streamline communications between GP clinics and external services such as specialists and hospitals.
Practices taking part in the HCH trial receive a one-off grant of $10,000 for set-up costs and bundled payments per patient, split into three tiers depending on complexity.
The top rate of $1795 per year is payable for a patient with the highest level of complexity, and the lowest is $591.
Major corporate involvement in the trial is a lot less than initially flagged, with 22 IPN practices taking part and 11 from Primary Health Care. Aboriginal community-controlled clinics number more than 40.
The government allowed $22 million for the trial last year, followed by allocations of $2.6 million in 2017-18 and $25.5 million in 2018-19, drawing on Medicare funds for chronic disease. An additional $30 million is earmarked for community pharmacy to support the trial.
However, there is no added funding at this stage for allied health care.
The AMA is calling for extra funding for the HCH trial in the 2018-19 budget.
