Tying patients to practices means a rethink of GP pay

The draft Primary Health Care 10 Year Plan is an ever-so-soft new tilt at shifting the balance of primary care funding to outcomes away from fee for service.

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It couldn’t hurt every GP to take a few minutes to flip through the Department of Health’s Primary Health Care 10 Year Plan to get a quick sense of what the powers that be are planning for them in the coming decade.

If you’re really strapped for time – it’s 59 pages and pretty fluffy in parts – turn to pages 12 and 29, and you’ll get a good enough sense of the plan: start tying patients to their practices as far as is practical as a means of developing a better base for longitudinal chronic care management within the community across the country, and perhaps, lay a platform for a better way of paying GPs into the future.

Page 12 sets the scene of introducing the tied telehealth payments, but page 29 is the money page; it confirms what really is on the governments mind:

“Payments linked to quality and outcomes measures, rather than fee for service, will contribute up to 40% of the blended payment mix” is a bit of a giveaway, not that it’s a surprise the government is shooting for that mix, as we’ve been here before.

“Payments linked to voluntary patient registration will be incentivising quality primary healthcare, including preventive care, and better health outcomes”, is another important positioning statement.

Of course, when we (they) say this could all be “better for GPs”, what “we” really mean is, it’s going to be better for patients and the healthcare system almost certainly, and we hope it will be better for GPs too.

That’s because no matter how you look at it, playing with funding mechanisms as well as long-established and cascaded-through health system payment protocols –  as fee for service for GPs is – is an activity fraught with danger.  

Short-term danger, at the very least.

Paying for outcomes and prevention should be better for everyone. So seeking to create much tighter connections between patients, their practices and related allied care is an important step to being able to create better community health networks, generate better localised population data, and manage patients far better according to their socio-economic and demographic needs.

If digital health reform is aligned appropriately to these changes, and GPs can network far more seamlessly with their patients, their hospitals and their allied health network, with the data flowing the right way, we are looking at the most important and seismic change to our healthcare system in history.

The signs are there that digital health reform is aligning to this plan, whether by design or happenstance.

In the last budget, the federal government set aside $50 million to develop a cloud-based voluntary patient registration (VPR) system, to be called MyGP, which was initially going to be used for the registration of patients over 70. But in this plan, this has been repurposed for all patients who want to use free telehealth with their GP. That system isn’t completed yet because of covid but it’s well on the way to being available.

At the same time, digital networked health initiatives centring on the ability of GPs to talk more seamlessly with both their patients and their key surrounding healthcare services are being pushed significantly to the fore by the Department of Health at the moment.

It seems likely that the DoH will soon introduce a framework for all health tech vendors, GP patient management system vendors included, and all healthcare providers (so that’s the GPs themselves) to be interoperable to certain key web-based standards within about five years.

That means GP systems will be far more able to talk seamlessly to hospitals, allied health, specialists and other key health providers, and in doing that create data sets that will allow the government to develop far more sophisticated targeting of healthcare funding based on regional needs and outcomes.

But we know all of these plans are great on paper but extraordinarily tricky in implementation and practice. We know this in part because we’ve failed a few times already at even getting started. Health Care Homes is probably our shining example of failure to launch.

Notwithstanding, this new mechanism to rope in patients (conscript them, perhaps?) is a pretty good one for both the patient and GPs. Telehealth got brought to the table only as a result of covid, but its utility in saving in system costs and patient time is out of the bag now, so it has come down to just how the government will regulate telehealth, moving forward.  

Everyone wants telehealth rebates to continue, so by tying them to this future system reform the government is playing one of its ace cards to get what it wants. It’s a much stronger hand to direct change than they held when they pushed out Health Care Homes.

Our reporter Francine Crimmins spotted this aspect of the plan the other day, and did a double-take: “It is proposed, subject to the consultation on this plan and the Government’s decisions following the consultation, that the VPR system would open for registration in July 2022 and that MBS telehealth for general practice would become contingent on the patient being registered with the practice from 1 July 2023. The ‘usual doctor’ requirements for MBS health assessments, chronic disease management plans and medication reviews would also be linked to VPR for registered patients from that date.”

Because it’s a big shift, and not one to which they’ve drawn anyone’s attention.

And the RACGP is mostly onside. President Dr Karen Price told The Medical Republic yesterday that the college supported the patient enrolment model proposed in the 10-year plan.

“Our position remains that telehealth should be available to patients who have an ongoing relationship with their GP, and we would be supportive of a voluntary patient enrolment model in the future,” she said .

The RACGP needs to replace the current 12-month rule for telehealth eligibility anyway. It turned out to be impractical and created quite a few problems for GPs, who read the rules differently to how the DoH ended up interpreting them, and ended up in trouble for claiming telehealth when they weren’t allowed to.

But the college’s support for tied telehealth funding goes a lot deeper than fixing its initial attempts at keeping fly-by-night virtual telehealth providers at bay.

“It’s important that a patient has an ongoing relationship with the GP or practice providing telehealth services to them to ensure quality of care, and prevent low-value use of Medicare-subsidised telehealth services,” Dr Price told TMR. 

“GPs who know their patients’ medical history can provide holistic care tailored to the patient.”

The 10 Year Plan proposes that for a patient to qualify they need to have had three face-to-face consults within the previous two years, and then they will need to have at least one face-to-face consult to continue to attract the rebate. There are important and sensible exceptions, which I’ll leave to those individuals prepared to read the whole 59 pages of the plan.

All things going well, it might be that the scheme starts as early as July next year, with practices being given until July 2023 to get their enrolments straight.

The RACGP doesn’t seem to be contemplating the longer-term goals that the DoH seems to have in tying patients into practices at this stage: which is to start building a basis for more block funding of primary care based on outcomes.

While the RACGP acknowledges these days the need to move to more of a mix, GPs are understandably nervous, based on the complexity, failure so far, and, well, no one likes big change, do they?

It’s not like the government has a great track record of pulling off big transformations like this.

You’d have to say at the moment, though, that their heart is in the right place: the government is moving in multiple ways to facilitate a system that can measure and manage outcomes better at the level of community health.

That’s good, right?

It’s great. But.

Like many plans before it, there’s a lot of soft wording in this 10-year plan that leaves a lot of room for the government to manoeuvre quickly should it have to.

Some things have been pointed out already by various commentators as being way too vague – such as, practices were going to be paid $156 to enrol patients over 70, so will this payment be made for the new enrolment system (which could get expensive quickly)? And does this payment make up any part of the move to a new mix of funding?

We have a federal election due soon.

If we are really moving to some form of block-funding arrangement based on outcomes, which could make up to 40% of primary care funding over time, could we perhaps have a bit more of a roadmap about how we are going to align these sorts of funding mechanisms with the right digital services, data requirements and the like with how practices operate today? These things aren’t currently available in our practice management systems and most PMS vendors don’t have the capital to make them available for free to suit the governments whims.

Paul Smith of Australian Doctor  made a very good point about the plan in his commentary on it that it doesn’t seem to have any integration or links to the other major government health plans in aged care, mental health and suicide prevention, and after-hours care.

He also thinks the plan is way too fluffy in parts.

“It makes the government look all action, but there is a certain irony to it all when none of those ‘plans’ seem that well integrated into this plan, which has apparently been two years in the making and is meant to range across the entire primary care system,” he concludes.

And one potential hiccup has already appeared in the form of a comment on our first story from lawyer and Medicare expert Margaret Faux, who has looked at the intention to incentivise practices to “conscript” patients and wondered out loud if in fact it might be unconstitutional.

“Any patient registration requirement that ties patients to a particular practice, where they have no realistic option other than to pay whatever fees are charged, may offend the civil conscription caveat in section 51(xxiiiA) of the Constitution, by being a form of practical compulsion,” she wrote.

“The constitutional provision applies equally for the benefit of doctors and patients – I think everyone forgets that.

“Patients have a right to access medical services from the provider they chose, because they pay for the system and the Medicare benefit is their ‘property’.

“One option would be for the government to force GP practices who register patients to bulk bill (as they have done during covid) – that would probably overcome any potential High Court challenges, but is unlikely to be popular.

“Or, as long as patients can quickly and easily opt out at any time, well, they probably will do precisely that to avoid fees … but that sort of undermines the whole concept.

“If patients are denied access to telehealth services just because they wanted to seek such services from a different provider to the one where they are registered, then that’s again a potential practical compulsion.

“This is going to be interesting.”

Yep, it is.