RACGP and AMA committee members say they managed to “safety net” the most radical aspects of the report, despite controversial recommendations. It could have been worse, apparently.
The long-awaited final report from the Scope of Practice Review envisions a future where blended payments will increase to 40% of GP income, the Heath Ministers’ Meeting has more power over AHPRA, and allied health can refer patients to non-GP specialists directly.
Multiple doctors who had been on the review’s advisory panel and sighted draft versions of the report told The Medical Republic that some of the more controversial recommendations had been altered or omitted entirely.
Where the recommendation to introduce a new blended payment model for multidisciplinary care was originally envisioned to use repurposed existing funding, for instance, the final report called for the new payment to be “supported by a growth in investment in primary care”.
“Absolutely no one will know how much we’ve managed to safety net the review from where it started to where it ended,” RACGP president Dr Nicole Higgins told TMR.
Dr Higgins stressed that the recommendations were just that: recommendations.
“We know that this is going to take a long time and what the recommendations are today mean that we will continue to be able to shape the outcomes for the future,” she said.
Review lead Professor Mark Cormack made 18 recommendations in total, reproduced below.
Of these, three stuck out as being particularly relevant for general practice.
Recommendation 12: referrals
Multiple GPs singled out recommendation 12 – opening up referral pathways to non-doctors – as having the biggest potential impact on the health system.
“Outside of referrals provided by specific named professions … regulations prevent the consumer from being eligible for MBS benefits for the referred service, resulting in out-of-pocket costs by default,” the final report read.
“For consumers, this creates both cost and time barriers to accessing primary care because, despite receiving care and referral advice from a health professional of their choice, they are often required to undertake a secondary consultation (typically with a GP) to access the required referral.”
Its intended fix is “direct referral pathways” that allow patients – whom the report refers to as “consumers” – to access non-GP specialist rebates when a non-doctor refers them to a specialist “within their scope of practice”.
A physiotherapist, for instance, might refer a patient to an orthopaedic surgeon, while a psychologist may refer to a psychiatrist.
Dr Higgins likened this to “opening Pandora’s box”, while AMA president Dr Danielle McMullen told TMR that it failed to recognise the breadth and depth of general practice.
“I do lots of mental health in practice and work well with psychologists, and they’re a really important part of the team,” she said.
“But there has also been a number of times where psychologists will refer patients back to me, saying they need to see a psychiatrist for management of simple depression and prescription of an antidepressant medication.
“That is clearly squarely within my scope, particularly as a GP who does lots of mental health … the patient doesn’t need to spend six to 12 months on a waiting list.”
Under the Scope of Practice report’s recommendation, the referral writer would also need to notify the patient’s regular GP and practice about the consult in an appropriate and timely fashion “via digital mechanisms as available”.
Failing to do so would prevent the patient from accessing the non-GP specialist rebates – however, it is unclear how this would be enforced.
“It’s also obviously really important that the rest of their health history and their medications make it onto that referral,” Dr McMullen said.
“GPs have been brilliant clinicians, by and large, in terms of writing referrals but also as stewards of our health system.”
Recommendation 10: a new blended payment
Fee-for-service currently makes up 90% of GP practice income, while incentive payments and other block funding makes up 10%.
The reviewers concluded that the prescriptive rules about which health professionals are funded to deliver which activities had the practical effect of limiting the scope of practice of those who were excluded.
“Introducing more flexible payment models to complement the predominantly fee-for-service payment model in primary care would better support primary care professionals to meet consumers’ health care needs (particularly complex health needs),” the report said.
The recommendation itself contains eight sub-recommendations that align with the goal of making fee-for-service 60% of GP practice income and blended payments making up 40%.
Patients and practices would have to be participating in MyMedicare to qualify, and the existing blended payments, like WIPs and PIPs, would be progressively moved under the MyMedicare umbrella.
Significantly, this would involve setting up an independent, specialised mechanism similar to the Independent Hospital and Aged Care Pricing Authority to decide on pricing and payment levels for block funding.
Don’t expect it anytime soon, though; implementation is proposed to follow a seven-year transition pathway.
Representative bodies like the Australian GP Alliance have long been supportive of an independent pricing authority for general practice, but generally wary of moves away from fee-for-service.
“We recognise that we need to do things differently and that we do need to be working in more collaborative teams, but we’re already running on the smell of an oily rag and we can’t stretch the current funding further,” Dr McMullen said.
“We need new funding, and I think that message has gradually been heard.
“The credit for that goes to the various advocacy groups who act on behalf of doctors, including us.”
Recommendation 18: rural Australians first
Professor Cormack’s final recommendation was that the government commit to prioritising the implementation of his recommended reforms in rural and remote Australia.
This should start, he said, with strengthening the capability of the primary care workforce, followed by support for health workforce innovation, new funding models and the introduction of direct referral pathways
“It’s true, we are really good innovators in rural and remote Australia,” Rural Doctors Association of Australia president Dr RT Lewandowski III told TMR.
“But I think we already have implemented the innovations he’s suggesting, and potentially you’re talking about dismantling things.
“We don’t need to be the guinea pigs, but we’re always happy to trial innovation if it makes sense.”
From the rural perspective, Dr Lewandowski said, there were some positives in being the first to trial reforms like the shift to a blended funding model.
“It is well recognised in rural and remote communities that the fee-for-service is not fit for purpose,” he said.
“I think the idea behind splitting [funding] between block funding as well as some fee for service or some ability to innovate makes a lot of sense.”
Related
On the other hand, Dr Lewandowski said, there’s always the possibility that the government will decide to generate money for block funding by removing the incentives that go to rural doctors.
He was also sceptical of direct referral pathways and how they would play out in rural communities in particular.
“It has the potential to do a couple of things, but one of the biggest is that it will lengthen the amount of time a patient takes to get care,” said Dr Lewandowski.
“If you directly refer a patient from a rural community to a non-GP specialist, which will definitely not be in that rural community, and you bypass things in the community like the local GP, the patient is going to wait longer, travel farther and gum up the specialists.”
ACRRM president Dr Rod Martin, meanwhile, pointed out that the reforms did not explicitly provide for referral to a GP or rural generalists.
“It … ignores the extended scope of practice that RGs possess to make more granular decisions locally, rather than potentially sending an underprepared patient long distances for further assessment,” he said.
Other recommendations of note
Some of the other more eye-catching recommendations included a mandate for primary care clinics to participate in accreditation, harmonising state-by-state regulations like those relating to prescribing powers, a bundled payment model for midwife-led maternity care and amending the laws to allow the Health Minister’s Meeting to give policy direction on registration and accreditation functions more directly.
Full list of recommendations
- Develop a National Skills and Capability Framework and Matrix
- Establish a primary care workforce development program
- Amend the National Law to provide a consistent authority of the Health Minister’s Meeting to give policy directions on registration and accreditation functions
- Develop principles for Interprofessional Education and interprofessional capabilities for primary care, collaborative practice and First Nations health care
- Remove unnecessary barriers to supervision in primary care education and training
- Progress activity-based regulation of scope of practice to complement the status quo protection of title approach
- Program of review and potential harmonisation of existing legislation and regulation
- Strengthen and standardise the regulatory model for health professions currently operating outside of the National Registration and Accreditation Scheme
- Establish and Independent Mechanism to provide evidence-based advice and recommendations in relation to significant workforce innovation, emerging health care roles, and workforce models that involve significant change to scope.
- Introduce a new blended payment to enable access to multidisciplinary health care delivered by health professionals working to their full scope of practice in primary care
- Introduce a bundled payment model for maternity care
- Implement new direct referral pathways for consumer access to specified non-GP specialist Medicare Benefits Schedule Items
- Program governance and reform structure to oversight reforms
- Develop a new capacity building and implementation support program for the 31 Primary Health Networks
- Develop and implement communications and training strategies
- Commit to a shared definition of cultural safety across primary care
- Mandate participation by primary care providers in an approved accreditation program
- Prioritise implementation of reforms in rural, remote and underserviced areas
