Issue 46 / 30 November 2015

REDESIGNING the health care system to reduce the demand on hospitals is a major financing problem for Australia. 
 
The rising costs of running our hospitals are well known. 
 
Reviews of the Medicare Benefits Schedule and primary care will be wasted if opportunities are not taken to the realign the roles and services provided by GPs and hospitals as part of a strategy to reduce health costs. 
 
So how could funding changes help to redesign the health care system in Australia so it provides more efficient, effective care and reduces hospital admissions?
 
One suggestion is to reinvest in general practice infrastructure so GPs can provide minor accident and emergency (A&E) services.
 
Analysis of Medicare data clearly document the decline of A&E type activity in general practice over time. As an example, I have put together a graph that demonstrates decreased laceration repairs in general practice over 20 years.
 
Similar declines have been noted in Medicare data for other GP-based A&E services including fracture management, removal of foreign bodies from eye/skin, and abscess/haematoma drainages.  Clearly, the general practice role in providing minor A&E services is in decline.
 
Conversely, hospital A&E activity is increasing and the cost of delivering minor A&E care has become exorbitant.
 
Emblematic of the absurdity of health funding in this area is the cost to hospital emergency departments when patients don’t wait to be seen. 
 
The Independent Hospital Pricing Authority report released earlier this year found that the “national efficient price” was $198 (based on the efficient price formula of 0.04 x $4971) for a patient attending a hospital emergency department who left a hospital without receiving any services. 
 
This equates to almost two-thirds of yearly costs of care for a patient seen in general practice and would cover several minor A&E attendances.
 
According to the IPHA, even the most basic hospital A&E presentation is “efficiently” priced at over $250. This contrasts with Medicare rebates of $44‒$99 for GPs to manage common laceration repairs [items 30026-30045]. Similarly, basic wound management is costed at $245 for hospitals, yet only $37 for general practice.
 
The price differential is simply irrational health funding. It is folly to think general practices would provide these services at a loss. It is policy madness to think that patients will go to a GP and be charged, when they can receive this service free at a hospital.
 
This incongruity in funding of minor A&E services has contributed to the patient shift from GP to hospitals at a considerably higher cost to taxpayers. The systemic divestment of GP-based A&E services over the past 20 years has contributed to higher health care costs.
 
If governments want a high performing, efficient health system they should promote general practice for minor A&E services to minimise attendances at hospitals. 
 
Critical in this model is the establishment of the medical home. The rationale for the GP medical home is to dedicate a medical practice where minor A&E services can be provided to patients rather than relying on hospital A&E departments. 
 
Providing facilities and services to perform minor A&E procedures similar to a hospital would establish a clinical alternative to encourage patients back to general practice. This should also include allowing GPs to dispense a limited group of emergency drugs, to effectively become a one-stop-shop for patients.
 
The result would be a convenient, effective place for consumers to address their A&E needs, without the long wait times often experienced in hospital emergency departments.
 
Current funding disparities have created a hospital-centric health system that is generating rising health costs. Reviews which simply look at the funding of existing services will not supply the answers we need. 
 
If Australia wants to address health challenges in a cost efficient and effective manner, funding opportunities to realign work practices between hospitals and GPs must be examined.
 
Re-establishing minor A&E services within general practice is a step towards reducing health costs that is simple and effective, and is something that Medicare reviews and political parties should consider.
 
 
Dr Evan Ackermann is a GP at the University Medical Centre, Southern Cross University, Gold Coast, Queensland, and the chair of the Royal Australian College of General Practitioners National Standing Committee – Quality Care.
 

Poll

Should governments fund minor accident and emergency services in general practice to reduce pressure on hospital emergency departments?
  • Yes – a great idea (66%, 83 Votes)
  • Maybe – if GPs have adequate training (26%, 32 Votes)
  • No – current system works (8%, 10 Votes)

Total Voters: 125

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8 thoughts on “Evan Ackermann: Cost solution

  1. max.kamien@uwa.edu.au says:

    A bit of common sense. Hope the minister is listening.

  2. Frank Jones says:

    Of course! Skills are already there :flexble practice accessability critical at local level

  3. Jan Sheringham says:

    Agreed Max, but unfortunately the cost of administering this proposal, while leaving ALL A&E services as free under Medicare agreements, would be astronomical! Already we see a new bureacracy being proposed to manage the mental health CDM processes, so despite being a common sense idea, this one is unlikely to see the light of day UNLESS some bright spark can find a way to get it across the line – perhaps a referral from A&E to the “usual GP’s practice”, where the service could be still provided free to patient BUT GP gets the full Medicare fee? Just a thought.

  4. Dr Philip Dawson says:

    A very big city-centric article, as country GPs haven’t stopped doing this (nor have all city GPs, I suspect). I think from experience some city-based practices dont want to do it, rather they find it more convenient to be fully booked with 3-week waits for appointments, rather than leave spaces for emergencies which may or may not happen. Perhaps you could do a breakdown of city vs counry, and distance from major teachng hospital? I know of several practices set up near or co-located with major teaching hospitals to service these minor emergencies, taking the load and waiting times off the hospital. Perhaps they bulk bill healthcare card holders? Country paitients will weigh up the cost of driving some distance and waiting hours for their minor laceraton to be sewn up at no cost to them, versus seeng their local GP who may charge a gap, which may be less than the cost of drivng.

  5. Gabriel Blecher says:

    The costs of minor wound repair may well be far higher in EDs due to higher fixed costs of staff and infrastructure. 

    realigning funding may help with overall costs, but won’t help with ED overcrowding. This has been shown to be due to bed block, not EDs being swamped by “GP-type patients.”

  6. Sue Ieraci says:

    The state/federal funding split makes the ED/GP cost-shifting argument interminable. EDs provide back-up for the entire health system – in-hours, out-of-hours, on public holidays, overnight, when the GP isn’t available, when the GP is unsure, when the GP can’t do the procedure, doesn’t have time.We don’t talk of “GP type” asthma vs paediatrician asthma, because these are all covered by Medicare, so no incentive to cost-shift.
    ED costs are notional, calculated over 24hrs, 7 days. GP costs are mostly incurred during “office hours” EDs have set-up costs to meet acute, complex demand – simple cases fit between the complex cases. What overhwhelms EDs is the high volume of complex elderly , & the risk-aversion that leads to “rule-out” testing. EDs provide second-opinions for the entire medical community.Many EDs run a low-complexity fast-track stream , so injuries and single-system illnesses are seen relatively quickly and easily.GPs: by all means continue – or re-skill – in wound care. Be available at short notice, around the clock. EDs are not fighting you for the trade. IF your patients choose ED for care, either because it;s available, or faster, or perceived to have more expertise in a particular area, they are probably making a rational decision. This GP vs ED tussle doesn’t help patients. (My comments relate to urban and regional EDs & GPs – many rural GPs staff their local ED).

  7. cameron mcpherson says:

    Ideas:

    1. Set up outpatient facilities adjacent to hospital A&E and have them staffed 24 hours.  

    2. Train nurses to handle these cases, esp. if we want to reduce the FFS nature of service provision.

  8. Sue Ieraci says:

    Hi, Simone. Many hospitals now have scant outpatient facilities during hours, let alone 24 hours 7 days? Who would staff such facilities, and how much would it cost to staff them? What services would they provide? EDs already have Nurse Practitioners working alongside ED doctors. The nature of their scope of practice means that they can;t really work independently. 

    24hour medical centres were a trend a decade or two ago. ALmost all stopped operatig overnight due to a lack of staff and/or cost-effectiveness.

    OVerall, though, we keep trying to solve the wrong problem. If it were not for the potential to cost-shift, we wouldn’t worry about which service sees the cut or the sore throat. The real issue is what to do about the increasing population of frail elderly with complex disease – the patient group that consumes more-than-ever GP AND ED services.

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