Position papers

Dec 2022
Rorts, and Revamping Medicare
Rorts and Revamping Medicare This series of three articles looks at the above topic under the headings:
  1. The Vision: Where could we be?
  2. The Reality: Where are we now?
  3. Implementation: How do we proceed with the needed changes?
The Vision: Where Could We Be? From a patient perspective A 45 year old woman feels vaguely unwell, tired, and achy. She books to see her regular GP at the practice at which she is enrolled. Because she is enrolled she has an appointment within a week. She’s menopausal but the GP is able to elicit more than the physical symptoms as she knows the family background and can gently probe. She needs some counselling and that isn’t a strength of this particular GP. She is referred to the on- site psychologist who works with her over several months but in discussions between the two health professionals in the corridor, they agree that her increasing weight gain might also be worth tackling more intensely and after appropriate discussion with her, she is referred to the on- site dietitian. The patient pays nothing but her taxes. There is no room for rorts. A 65 year old man being treated for prostate cancer is discharged from the oncology unit with follow up appointments. He takes with him a discharge summary (also sent electronically), written by the registrar or senior resident, with a one to two paragraph summary of the admission, a list of alterations to all his admission medications, a summary of relevant results, prognosis (which has been discussed with him), further follow up, and a direct contact to the registrar. The summary cannot be five pages long. He sees his usual GP within a week at the clinic where he is enrolled and on his return for follow up a letter from that appointment written by the registrar or consultant is posted. It is a report on the follow up, not a five page templated report comprising his life history! A 28 year old man from Afghanistan sees a new GP following his recent release into the community. He comes with a volunteer support worker. The GP spends an hour assessing him through a telephone interpreter service. He refers within his medical centre or nearby facilities to the full range of allied health workers needed. A case worker is assigned to him to liaise with non- medical help for housing, employment and the like. After assessments by the various professionals a case conference is arranged at which most of those involved can contribute. Even his major chronic dental issues are addressed. The patient pays nothing but once working, he will pay through taxes.  There are no rorts. A 40 year old cyclist falls off his bike almost outside a medical clinic. His elbow is very painful. He is seen almost immediately by a paramedic trained physician’s assistant (PA) who organises an x-ray nearby and within an hour can tell the full story to one of the GPs who agrees that a non-urgent review by an orthopaedic surgeon is needed along with rest and analgesia prescribed by the PA. It takes two minutes of the GP’s time. The patient is seen at the public hospital outpatients within a month. No rorts. A recently diagnosed 55 year old woman with diabetes has been started on insulin and needed antihypertension treatment as well. She presents to her usual medical clinic where she is assessed by the nurse and the diabetic educator, found to have a low sugar but normal blood pressure and quizzed appropriately regarding her eating times. The cause is dietary. Advice is given. The GP is consulted by the nurses and the patient is sent on her way. It takes less than five minutes of the GP’s time, just being consulted by the nurses. No rorts. It's a small country town which can’t attract a GP. There’s a pharmacy next to a community health centre where there is a nurse practitioner and a physiotherapist. The nearest medical clinic with GPs is two hours away. A GP visits every two weeks for the day. Patients attend daily, assessed by the salaried NP, who is authorised to arrange blood and urine tests and ECGs, initiate some medication e.g. for infections, and re-prescribe many regular medication. The NP has a direct line to the medical clinic two hours away including for after-hours calls. Compared to what existed previously this is wonderful for patients who don’t pay anything except through their taxes. No rorts In an Aged Care Home a resident is noted to be have new mild urinary incontinence, hardly eating, and slightly confused. The nurse arranges a urine test which comes back as an infection with pyuria and no contamination so she informs the senior nurse who notes this is a somewhat recurrent problem and contacts the nurse practitioner who prescribes her antibiotics. The GP notes this at her next visit. It’s sorted. No rorts. From a specialist general practitioner (SGP) perspective SGPs are salaried, working full or part-time as appropriate to their choices. The medical centres in which they work are sufficiently large (except in remote areas), to also employ multiple allied health staff either full or part-time, and nurse practitioners or physicians assistants where appropriate. They are paid salaries comparable to non-GP specialists working in public hospitals. In addition to their salaries, they are supported financially to maintain continuous professional development (CPD). This would include CPD embedded in the medical practice in which they work with an emphasis on comprehensive integrated care. Salaried providers could rort by being lazy but are surrounded by a team. Little room for rorting, just like in public hospitals. Those who wish to run private practices would face the same challenges as they do today. From a non-GP specialist and dentist perspective Little would be different for public hospital non-GP specialists except that they would be responsible for ensuring a hugely improved discharge summary and outpatient appointment communication. Some however, may be working on salary in community medical centres. For those who work in private practice, the only change to their non-hospital work would be that there would be less work, as public hospital non GP-specialist numbers are increased to cope with demand. From an Allied Health Worker/Nurse/Nurse Practitioner/Physician Assistant perspective Many would be delighted with the opportunity to work in a team with different health professionals, constantly evolving new understandings of the complexity of care, able to work to the full capacity of knowledge, training, and experience. From the perspective of the relatively well financed patients Private care would remain available to all. but billionaires would continue to be entitled to the full range of publicly provided health care as those struggling on the parsimonious job seeker ‘benefit’. Those who wish private hospital care would face higher private health insurance (PHI) premiums because the grossly unfair and inefficient PHI rebate would be gone.   Part 2 The Reality: Where are we now?  From a patient perspective Patients in remote areas have to travel hours to see a specialist general practitioner (SGP). In the small town there is a pharmacy and there are nurses and perhaps even a paramedic or nurse practitioner who aren’t working in their profession for all sorts of reasons who would be only too willing to help but are constrained by professional demarcation disputes based on models of care from the 1960s. Patients in the poorer big city suburbs usually can get bulk billed services but may have to wait weeks to see a doctor and often cannot get to see their regular doctor. In more affluent areas many of the practices do provide that continuity of service but at a price which is challenging for poorer patients in richer suburbs. Even to get a repeat prescription for a drug a patient has been on for 10 years can be a challenge. Getting to see a non-GP specialist (nGPS) is an even bigger challenge given that private nGPSs bulk bill only 33% of consultations (July 21-June 22 Medicare statistics). The alternative is to wait a year or three for a public hospital outpatient appointment, often seeing the same nGPS that would charge a $150 co-payment which forces them onto the waiting list, currently worse because of Covid. Patients in not so remote country towns can wait weeks to see any doctor and in some areas the turnover of doctors means they build up relationships with a doctor which only lasts twelve months because the doctor, usually overseas trained, is heading for the city and spending initial time in the country just to get established. Patients discharged from hospital may be able to get in to see their usual SGP within a week, but even then there is a reasonable chance that the SGP will either have no discharge summary or one written by a very junior hospital doctor filling in a template with pages of unnecessary information and no information on why drugs prescribed by the SGP were stopped and whether they can be started again. There may be referrals to different hospital outpatients for follow-up, but these appointments may be months away, leaving the SGP to deal with whatever issue in the meantime. This is usually done very well by the SGP but sometimes for all sorts of reasons including if it is not the usual SGP it may not be done well. Patients with drug addiction issues struggle daily to manage their illness. Frequently there are major mental health issues as well. But so often they present to an Emergency Department which simply doesn’t have the resources to deal with them. Most SGPs don’t prescribe methadone so if that is one of their needs, they may struggle to find a treating doctor to even have methadone considered. Specialised addiction clinics exist but there aren’t enough especially outside of big cities. Often they are faced with the siloed approach where the doctor can treat the mental health issue but doesn’t treat addiction which is addressed at another facility. It’s tough enough for them to get to one source of help, let alone face a trip and repeated assessment at another. Patients are often held back in their job seeking because they have rotten teeth and can’t afford private dental care and have been waiting five years for public care. Shame about their appearance is a powerful negative force in their lives. Patients in Residential Aged Care facilities struggle even to get basic nursing care let alone consistent high quality medical care (until they have to go to hospital: often a completely preventable admission). From a specialist general practitioner (SGP) perspective SGP numbers are declining as there are not enough medical graduates taking on the 3-4 year training required to enter a specialty which is undervalued by many non GPSs, successive governments both Labor and Coalition, and the public. They work in an environment which doesn’t support the best use of allied health, doesn’t seriously promote a focus on prevention, and largely ignores the social determinants of health (Job Seeker being such an obvious example: poverty kills).  SGP attrition is not just due to age but increasingly due to doctors deciding to leave general practice and work elsewhere. Whilst nGPS’ incomes vary considerably, a staff specialist in NSW starts with salary of $230,000 with no practice costs. After seven years this rises to a minimum of $317,000. Non-GPSs train for 3-7 years so perhaps two years longer. When finishing one’s degree or doing internship a doctor is faced with a HECS debt of $100,000 (courtesy of Labor killing off free university education introduced by Whitlam), and a choice to go into a profession which is undervalued, very busy, and relatively underpaid. Is it any wonder that numbers are falling. From a non-GP specialist perspective This would depend on whether you are living the good life, working furiously, earning over $300,000, and not at all concerned that your co-payments force desperate patients onto public waiting lists and prolonged preventable suffering, or whether you do have an interest in ensuring all patients have a fair go and work hard to make that happen. From an Allied Health Worker/Nurse/Nurse Practitioner/Physician Assistant perspective The many such professionals who don’t work in standard fee for service businesses work in environments under pressure, sometimes sufficiently rewarding to take the pressure, but often not. Their contributions are often not valued sufficiently just like SGPs. From a media perspective There is a story to be told about rorting and whilst it clearly occurs, the media have failed to rely on hard evidence of the degree of rorting, partly because it is unknown. Rorting whether intentional or otherwise, should be minimised but isn’t. That is a failure of successive governments and the system they have constructed. The reality is that the media want spectacular stories and the reputation of health providers using Medicare is tarnished without adequate perspective.   Part 3 Implementation: How Do Proceed With the Needed Changes? How do we move towards a humane, efficient, effective health system as outlined in Part 1 when we have a Federal Government which feels financially constrained by the long-standing belief that new spending on basic things like equitable health care is only politically and financially acceptable if such spending was promised prior to the election? Can the Federal Government make small or moderate moves now which will not commit much money but will start the process to revamp Medicare? Can it over time, see that investment in improving Medicare is both economically and socially desirable, enabling it to embark on the bigger changes required? Primary Health Care. There is light at the end of the tunnel. The very conservative Australian Medical Association has come out in support of patient enrolment in primary care. Enrolment with a particular Specialist General Practitioner (SGP) or Medical Practice (MP) which may not have SGPs (the ‘may not’ being the reality in some rural and remote communities), can form the basis for reform of Primary Health Care (PHC). For enrolment to work there needs to be an easily seen incentive or benefit to both the SGP/MP and the patient. The initial step could be to change the mechanism of funding for the many different practice and provider incentives which currently exist in general practice. First, an enrolment fee can be introduced. This already happens for Aboriginal and Torres Strait Islander (ATSI) people. Second, the payments for all of the various incentives need to be adjusted according to socio-economic status (SES) of the patient’s location. The information is available to reduce this to areas called MESH blocks containing 30-60 dwellings. Some of the payments are already adjusted for age and gender, so adding SES would not be a problem. This would immediately mean that providers who take on the challenge of working in areas of low SES status would receive extra funding but those in wealthier areas would not be disadvantaged. Treating an 80 year old retired judge with high blood pressure and heart disease is not as challenging or time consuming as treating a non-English speaking refugee with a dysfunctional family and a history of torture. Over time however, there needs to be increased rewards for the providers in wealthier areas. These many incentive payments can then be increased and converted into a capitation payment. It’s worth noting that New Zealand SGPs receive 50% of their income as a capitation payment. How does the patient benefit? The initial payment for enrolment needs to be partly and variably contingent upon delivering certain levels of continuous care to the patient. This already occurs with ATSI patient payments. The additional payments could then also be made contingent on such care. The next step could be to have the capitation payment sufficiently large to also require bulk billing i.e., a universal health system. That is different from a universal public health insurance scheme which simply gives access to an inadequate rebate i.e., Medicare as we know it. Universal bulk billing cannot possibly be introduced however, until the many practices in wealthier areas which believe they can’t manage without co-payments are satisfied that the extra funding will enable them to survive. The final step could be to then stop fee for service payments altogether for enrolled patients, or at least to those being treated for chronic diseases. Rorting is so much harder in a salaried service. Private Hospital and Private Non-Specialist Care So much for primary health care. What about non-GP specialists (nGPSs) and hospital care? It should be obvious to anyone that public hospitals need more resources including nurses and doctors. A simple first start for the Federal Government which unlike the States and Territories, can print money, would be to fund more nurses and doctors in public hospitals and Medical Centres on the proviso that services are free at the point of service just like they are currently in public hospitals. Doctors and nurses work for a salary in public hospitals. There is no reason to expect that can’t continue. To fund such a measure the obvious source of funds in the long term is the inequitable private health insurance (PHI) rebate which permits those who can afford PHI to avoid the queues the majority of Australians face at public hospitals. The rebate cannot suddenly be ceased but could gradually be reduced with the simple argument that in these financially difficult times when the Coalition is demanding an improvement in the budget, the sensible thing to do is to reallocate spending to where there is demonstrable greatest need, i.e. public hospitals. Savings could also be used to fund the other obvious area of need, primary health care. With an increased capacity of public hospitals, waiting lists might stop getting longer even as some patients are less able to afford PHI and use the increasingly better resourced public hospitals. Rorting will continue in the much less publicly subsidised, smaller private hospital and health sector. The Big Picture Moving from predominantly fee for service funding to predominantly salaried practice or some form of capitation would minimise the risks of rorting. Ultimately however, the grossly inefficient debacle of Federal, State and Territories, and Local Government funding of health services needs to be addressed. A National Health Care Reform Commission needs to be established as the single funder of public health care, independent of politicians and the many stakeholder groups. Charged with distributing funds on the basis of need, it would be a long- term project. Politicians only decisions would be how much to fund the total health care budget and who to appoint to the Commission. It would require detailed population health data collected at the regional and practice level. That in turn would require defined funding to medical practices and primary health care networks to collect, with minimal imposition on front line staff. As well as the Commission we need a restoration of Health Workforce Australia and a Preventive Health Agency because without developing our workforce nothing can happen, and without prevention we are asking for a tsunami of preventable illness and death. The first steps could start now or at least with the next budget especially given that the first steps are not expensive. It would take vision from Labor, and it would take their call that they are the only friends of Medicare to be about action rather than rhetoric. Despite the AMA’s commitment to patient enrolment, they would object to capitation and other changes because it reduces doctors’ autonomy even if most SGPs could be financially better off. The PHI industry and private hospital industry would object because it would very simply affect their bottom line i.e., profits. But our health services should be first and foremost about patients. We need doctors, nurses, and the various other providers but the system should be there to focus primarily on patient need, not on the antiquated view of some providers as to how a 21St century health system should be. It is all possible. It is a process which can be started now with little cost. Our patients lives depend on reform. Our society can be healthier. We can have a health system rather than an inequitable, inefficient, unco-ordinated collection of health services. We have dedicated health providers. We are wasting their talents and both our patients and our country are losing out. Dr Tim Woodruff Chair Australian Health Care Reform Alliance