The reprieve on chronic care plans is just a brief delay on the journey to non-viability. And the ‘Viking’ solution is no solution at all.
After months of uncertainty and confusion, which is unfortunately the norm in Australian general practice, the Department of Health and Aged Care has put a temporary stay of execution on the policy to remove and dismantle much of the chronic health care planning item numbers.
The dysfunctional management style of coming up with a policy and then, on the run, trying to figure out how it will be executed or disbanded continues in the one area of healthcare that remains cost-effective and efficient in reducing hospitalisation and morbidity and mortality.
As the costs of running a practice and providing high-quality general practice-led primary healthcare in Australia continue to mount, this is merely a pause before the hammering of the next nail into the coffin of general practice.
The pressures of working, particularly in outer metropolitan practice, continue to mount. For instance, here in southwest Sydney we have just had the 37th practice close this year due to the increasing non-viability of providing GP care in a diverse and challenging community.
Outer metropolitan practice continues to struggle with the needs of a complex patient cohort. Southwest Sydney has a population of about 1.2 million, being served by about 1100 GPs. We have around 400 general practices still operating but only 300 are accredited. It is an area with significant healthcare needs and lacking healthcare infrastructure and abundant in risk factors for poor health outcomes such as education, employment, socioeconomic status and Aboriginal and Torres Strait Islander or refugee health-related disorders.
The ongoing challenges of significant health issues, combined with a stark lack of remuneration, means that the workforce continues to struggle.
The median age of GPs in southwest Sydney is now 53 years. Almost 30% are over 60; in some southwest Sydney regions the proportion is 43%. This reflects the difficulty of attracting medical students to consider general practice and then to work in areas of significant need, particularly where Medicare does not cover your costs and your patient cohort cannot make gap payments.
The issues remain simple.
Medicare does not adequately fund quality general practice. Areas of financial need cannot rely on patients to make up the funding gap. This is why in southwest Sydney, where some council areas rate among the most socioeconomically disadvantaged in the country, we still have three more practices closing before Christmas and another seven at risk.
The non-viability of practice is becoming one of the biggest risk factors in poor health outcomes and increasing incidence of multiple chronic health diseases. The increasing morbidity of the population directly increases the burden on local hospitals.
The Medicare rebate currently covers around 45% of the costs of running a practice – costs that have risen over 6% this year. So it seems that GPs here have the choice of closing down their practices and moving to more affluent regions, where people are healthier and able to afford the ever-increasing gap fees, or continue the insurmountable struggle to keep their doors open with inadequate Medicare bulk-billing funding.
That means either relying on chronic healthcare planning rebates or turning away from quality care and submitting to Medicare’s incentive to practice poor-quality fast-throughput healthcare, as it is the only way to keep doors open.
This is why I have been so concerned with the months of confusion regarding the department deciding to cancel a bulk of chronic health management plan item numbers, with plans to shelve health assessment numbers as well.
These item numbers are one of the only sources of funding sustaining a number of practices in our region and other regions of socioeconomic disadvantage. Removing these would lead to the inevitable closure of more practices and poorer health outcomes – but this straightforward logic doesn’t seem to resonate with decision-makers in the Department of Health and Aged Care.
The items at risk are also very much under-remunerated. The system encourages me to see patients every six minutes and, with bulk-billing incentives, bill over $600 per hour for the practice. For me to concentrate on high-quality medicine, there must be a substantial increase in rebates for longer consultations, health assessments and chronic care management plans to match that $600 per hour in practice income.
The proposed “Viking solution” – pillage the rest of the world and import a further 5000 overseas doctors to work in Australian general practice – is definitely not the answer.
Preying on the meagre health resources of other nations is not a good look for a mid-sized global citizen. Bolstering your GP numbers by importing doctors from nations that lack primary care systems or do not have a significant primary care culture creates significant disruption and disturbance in primary care health management.
Facing the combined stresses of a new location, new language and new system while being thrown into outer metro regions like southwest Sydney (where already half of the GPs are international medical graduates) with high-complexity patients and low health infrastructure is an unsafe and inappropriate Band-aid.
Our international colleagues need and deserve significant support and training during the transition for Australian system primary care work and unfortunately this doesn’t seem to be the case in the areas of most socioeconomic disadvantage and need.
About three-quarters of the GPs in my region live, work and consult in a language other than English. That is, 900 of the 1200 GPs consult in 64 languages.
Do these dedicated, hard-working doctors receive the government support they require to provide quality care in such areas of need? Or is the lack of support and funding contributing to the low levels of practice accreditation, burnout and non-viability culminating in the continued closure of GP clinic services?
Nobody disagrees that Medicare and particularly primary care need reform to improve patient outcomes and attract doctors to train in general practice. Current solutions have not worked and it is looking more likely that ideas like MyMedicare also will fail.
We have had a sneak peek into what MyMedicare may look like with the change in GP aged care incentives funding.
The new incentive model is an absolute disgrace: highly complex, full of red tape and a minefield to navigate through. The vast majority of GPs I’ve spoken to are going to be worse off under the new system, thanks to losing funding for aged care visits and managing patients in residential aged care.
It is likely that the new MyMedicare general practice aged care incentive will lead to fewer GP visits to residential aged care and worse outcomes for residents, namely increased mortality and morbidity and shifting pressures again to local health district emergency departments and hospitals.
This new system is a prime example of how to disincentivise the outcome that the system was supposedly trying to achieve.
Dr Kenneth McCroary is a GP in Campbelltown, a lecturer at Western Sydney University and University of NSW, director and clinical co-chair of SWS PHN Aged Care & Mental Health, and chair of AMA NSW’s Council of General Practice.