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Providing high quality care doesn’t pay

Current funding arrangements for general practice do not reward quality care and must be overhauled, the AMA National Conference has been told.

While not calling for the current fee-for-service model to be scrapped, speakers at the policy session Funding quality general practice – is it time for change?  said better patient outcomes could be achieved with changes to the way doctors are remunerated.

Former GP of the Year and Clinical Director of the Australian Primary Care Collaboratives Program Dr Tony Lembke told the Conference that although Australian practitioners provided high quality care, funding arrangements placed road blocks in their way.

Dr Lembke said there was a tension for general practitioners between their professional aspirations to provide quality care and the demands of running a business.

“The more I look after disadvantaged patients, those with chronic disease, or who are in aged care; the more time I spend training students, the less my income is,” he said. “That is a bizarre sort of system.”

Dr Tim Ross, National Medical Director for health insurer Bupa, said a shift was underway toward more team and community-based care, and the way GPs were remunerated needed to change to reflect and support a different model of providing care.

Bupa last year began trials of GP clinics where patients make a private payment for treatment which emphasises follow-up care and close co-ordination with specialists.

Dr Ross said he expected the Commonwealth to eventually adopt a capitation model of payment, where GPs are paid an annual fee to care for a patient, rather than be paid by service.

This would be part of a blended model including bundled payments from government, fees for services rendered and financial rewards for quality care, including outreach to patients.

He said a team-based approach to care would mean patients seeing a physiotherapist, psychologist or other allied health professional would not need to see their GP in order for funding to occur.

But AMA President Dr Tony Bartone said that providers carried the risk in a system of bundled payments, and the funding model encouraged cherry picking of patients.

Dr Bartone said the fee-for-service model often got a bad rap for issues that had more to do inadequate indexation of Medicare rebates and poorly designed Medicare Benefits Schedule items.

He said there was no evidence that any alternative funding models were superior to fee-for-service, a point admitted to by former AMA Presdient Dr Steve Hambleton, who has been appointed by Health Minister Sussan Ley to lead the Primary Health Care Advisory Group.

The Group has been established to make recommendations on how to provide better care for chronically ill patients and those with mental health conditions, as well ways to improve the co-ordination between hospitals and primary care, and to look at “innovative care and funding models”.

Dr Hambleton told the Conference the work of the Group, which is due to report in November, would be evidence-based.

Currently, he said, “there is no clear winner in terms of which [payment] system is better for outcomes, but we all know there are places where we can do better, [where] we can align the business and professional imperatives better”.

“It does not mean we throw out fee-for-service, but is there a way to say that, if you spend longer [with a patient], if you think about it longer and spend time planning a bit longer, how do you reward that?

“At the moment, the short you spend [with a patient], the less time you spend, the less you think and the less you talk, the more you get paid,” Dr Hambleton said.

A video of the policy session can be viewed at: media/ama-national-conference-29-may-2015-session-2

Adrian Rollins