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Pay for GP performance no health solution

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AMA President Dr Steve Hambleton has warned the introduction of performance pay for doctors risks compromising care and should only be considered as an adjunct to the current fee-for-service model.

Federal Health Minister Peter Dutton is considering a fundamental shift in the way GPs are paid as part of an overhaul of health funding, and has raised the possibility doctors would be paid an annual fee to care for their patients as part of a “blended” system of payments, often referred to as capitation payments.

The Minister told a general practice conference last month there was “an opportunity for us to perhaps look at doctors and other stakeholders in the conversation about blended payments”.

And in a speech to the Australian Private Hospital Association on 24 March, Mr Dutton said it “makes no sense” for taxpayers to foot almost all the bill for primary health care “when the patient is prepared to contribute to their own costs”.

“The focus of the Commonwealth should be on getting our primary care response right, particularly for the chronically diseased and aged,” the Minister said. “We need to look at the payment models and the way in which we manage the most frequent users.”

Mr Dutton voiced keen interest in increasing the involvement of private health funds in the provision of primary care, noting approvingly the Medibank Private trial with several GP clinics in Queensland, the HCF after-hours GP service for members and the deal struck by Bupa with medical centre operator Healthscope.

“I am encouraged to see that health insurers are looking at innovative options in the area of primary health care,” he said. “They have been excluded from the primary care space for historical reasons, and if insurers are prepared to work collaboratively with doctors and patients, then we should welcome that development.”

The Minister said he would not consider initiatives that would involve patients opting out of the Medicare system, but would entertain ideas that would allow insurers to target “frequent users” of GP services.

The nation’s largest health insurer, Medibank Private, has backed the idea of capitation payments to doctors, arguing that they would encourage GPs to keep in regular contact with patients and to make follow-up calls with specialists as part of efforts to keep high-needs patients out of hospital, so avoiding unnecessary costs.

But Dr Hambleton cautioned pay for performance systems for GPs carried a number of risks without necessarily delivering much in the way of better care.

The AMA President told the International Primary Health Care Reform Conference in Brisbane on 19 March that international experience showed that while pay-for-performance systems changed the way doctors worked, there was little evidence to suggest they saved money or improved the quality of care.

“Cochrane reviews of a range of schemes in a range of countries that use financial incentives to reward performance and quality have determined there is little rigorous evidence of their success in improving the quality of primary health care,” he said. “Nor is there much evidence pay for performance is cost effective relative to other ways to improve the quality of care.”

Several leading health policy experts, including Grattan Institute Health Program Director Professor Stephen Duckett and UNSW Emeritus Professor of Medicine John Dwyer, have joined the AMA in describing proposals for a $6 patient co-payment for GP visits as a distraction.

Instead, they have urged a more ambitious and holistic approach to reform that directs funding toward tackling the underlying causes of ill health and hospitalisation, particularly the rise of non-communicable diseases associated with poor diet, inadequate exercise, smoking, drinking and other harmful behaviour.

Professor Dwyer said integrated primary health care programs with a focus on education, prevention and early diagnosis would, for an initial upfront investment, save billions of dollars and improve national health, citing as evidence research showing 600,000 hospital admissions could be avoided each year with effective community intervention in the preceding three weeks.

Dr Hambleton said that through the current fee-for-service funding model GPs were providing excellent value for money, and the Government should increase support for them to provide the sort of care needed to maintain help and keep the chronically ill out of hospital.

“Fee-for-service should remain as the cornerstone funding source for general practice,” the AMA President said, accompanied by greater support for longer consultations, more effective support for chronic disease management and “appropriate mechanisms for quality improvement”.

He said the AMA was prepared to consider blended payment models as an adjunct to fee-for-service payments, but was wary of the potential for adverse outcomes.

Dr Hambleton said the risks of performance payment arrangements could not be ignored, and included the potential for doctors to focus only on activities that were rewarded, to cherry pick healthier patients rather than taking on those with chronic and complex conditions, to encounter greater red tape, and to subject them to inappropriate criteria.

He said there was already an imbalance in the existing rebate system that rewarded high patient turnover rather than extended consultations and team-based care, and warned any pay-for-performance system would need safeguards to ensure the quality of care was enhanced rather than undermined.

It should be a supplement to fee-for-service payments, align with clinical practice, be indexed, encourage appropriate clinical and preventive health care services and minimise administrative burden.

“It is all about the right care at the right time in the right place by the right practitioner – the GP,” Dr Hambleton said.

Adrian Rollins