It seems that a proposal to reward doctors for “enrolling” patients with higher care needs, such as young children and those with chronic diseases, has caused a bit of debate amongst the community of general practitioner community.
The idea first came to attention in the National Health and Hospitals Reform Commission’s final report, which proposed that such individuals “have the option of enrolling with a single primary health care service to strengthen the continuity, coordination and range of multidisciplinary care available to meet their health needs and deliver optimal outcomes.”
In a nutshell, the idea is that these kinds of patients aren’t being looked after properly by the current fee-for-service payment structure for GP’s, and that their care isn’t being properly integrated when they see multiple health care providers. So if we encourage GP’s to take on these kinds of patients, be the primary coordinator for their health care services (like the family doctor used to do), and provide the appropriate level of care, they will be better managed.
The report also recommends a bunch of other changes to support the enrolment model:
To support this, we propose that
- there will be grant funding to support multidisciplinary services and care coordination for that service tied to levels of enrolment of young families and people with chronic and complex conditions;
- there will be payments to reward good performance in outcomes, including quality and timeliness of care, for the enrolled population; and
- over the longer term, payments will be developed that bundle the cost of packages of primary health care over a course of care or period of time, supplementing fee-based payments for episodic care.
The current implementation appears some way from this, offering a flat fee of $100 to doctors for enrolments, leading to the concern that doctors seeking to maximise their financial return will simply enrol as many relatively low-needs patients (such as healthy toddlers) and leave the more time-consuming and costly patients even worse off than before.
However, in the report, and in the reportage in the news, I can’t see any discussion of what this kind of proposal would mean for patients, and why they would participate. What’s being “enrolled” with a GP going to do for you if you’ve got diabetes or a heart condition (or Crohn’s disease)? Why are people with such conditions going to multiple GP’s in the first place?
Of course, there’s another approach to changing care incentives – get rid of fee-for-service entirely and make doctors salaried employees of a government body. Anybody want to bet on the odds of that ever happening?
Maybe because it can be so hard to get into see a GP at short notice that people end up going to see who is available rather than the one they want to see? Removing choice of which GP you can see seems to be a very bad idea to me.
They’ve recognised a problem with lack of continuity of medical history and decided to solve it by stopping people from going to different doctors. Pretty stupid.
Integrated electronic medical records. Why should it matter which doctor you see.
Andos @ 2 – because its much easier just to tell everyone to see the same doctor
I’d much rather see this problem tackled with the financial incentives at the other end. That is for eligible patients have a gradually increasing rebate each time they see the same doctor. This would create an incentive for doctors to treat these patients long term while the patient keeps their freedom to change doctors if they become dissatisfied or their primary doctor is unavailable.
Taking it further perhaps we should start having payments to doctors calculated on the basis of problems treated rather than just patient visits, i.e $X / patient / year for a given chronic disease.
Because there is much more to patients than what is in their medical records.
Hi Robert, I’ve got Colitis and I do indeed go to multiple GPs. The reasons stated above caputre it. My “real” doctor costs money, is usually booked at least a week in advance, is nowhere near where I work, and has a long waiting period. The take out is, I want to see my “real” doctor, I have to work from home for the day, wait at the surgery for 40-60 minutes, and shell out sixty bucks for it. I don’t begrudge my doctor any of those things, but when I just need a script filled, it’s a bit of a song and dance.
Hence my “dodgy” doctor. Free, next door to work, waits are only 10-15 minutes, I’m in and out very quickly. This has had the regrettable side affect that thigns like immunisations etc are now a bit all over the shop.
What Chris said.
@ patrickg – a week, I’d love a week! Three weeks is the norm here. Although you can call at 8.30am on the day and try to get the on-call doctor.
Electronic records don’t solve much on their own. My town just had 2 and a half years of different locums – all of whom were perfectly good doctors – meaning that every time you went to see the doctor, you had to go through your entire medical history again. They had your full record right in front of them, but that doesn’t tell them everything. I have a complex medical history involving a rare cancer, and while I felt confident discussing this with many different doctors, a lot of elderly people didn’t. The pharmacy (where I work) saw many, many more scripts from doctors from surrounding towns – not because waiting time was shorter (it certainly wasn’t), but because patients could see the same doctor every time.
Continuity of care is important, and if these incentives make it easier to see the same doctor every time for your regular care (without removing the ability to go elsewhere for emergency care) that would be terrific. These chronic patients could then have all records automatically sent back to their primary GP.
We now have doctors again, and I really hope it will last.
My “real” doctor costs money, is usually booked at least a week in advance, is nowhere near where I work, and has a long waiting period. The take out is, I want to see my “real” doctor, I have to work from home for the day, wait at the surgery for 40-60 minutes, and shell out sixty bucks for it.
*Nods* Yeah, snap.
What Mindy said…. 3 weeks to get into my real dr, call between 8:30 and 8:40 for an “Emergency” slot if I’m feeling crap and need more than a day or two off work…
Problem with that is that even though it’s at the same pracitse and there is one computer record, you still have to tell things again, and things get missed…
I write notes on clinet files as a speechie, and there are things you just know about the people you see that don’t necessarily make it into the notes… particularly if they are meant to be objective!
Continuity of medical records isn’t a magic bullet, but it would help. For example there are tests that were done on me about 8 years ago which that would have been very useful for my current doctor (I think they were predicting some problems I am having now, but my recall is not that great and I never wrote anything down). Unfortunately I lived in a different state at the time, the doctor I saw then has retired and the medical practice he worked at has closed down so I’ve no hope of getting access to my old records. I also ended up with an accidental dosage change in one medication I take when I moved interstate because I had run out and misremembered what dosage I normally take when I spoke to my new doctor. That sort of error would be easily avoidable by having portable medical records.
Solutions to address continuity of care has to take into account that people (and doctors) move. Some people move around a lot.
At least we’re very lucky where we live now – we go to a practice that promised they would see our daughter (who was 6 months old when we moved here) the same day if it was urgent and so far they have always followed through and have always been able to squeeze her in (and we don’t have to wait around for long periods). Of course we can’t always see the same doctor at short notice, but thats not unusual as there are lot of GPs who work part time.
You managed to write a whole post on this without mentioning the f word – fundholding. That’s what this is really all about. Governments – and Treasury in particular – hate the fact that GPs are the one area of health spending they can’t cap. The answer is to get GPs in to Super Clinics, then give them an X dollar fundholding deal for looking after all patients with diabetes and Y dollars for asthma. Then when the cash runs out the Super Clinic has to do some cost cutting in other areas to make up the shortfall – just like hospitals. As for performance incentives – works well for clear cut things like immunisations, but it’s no panacea. You end up with one-size-fits-all medicine because the computer says all people with diabetes should be taking a statin and aspirin, even if they’re 103 and intolerant of aspirin. Roxon’s plans will also bring in a whole load more paperwork and need more managers and monitors. Medical graduates will continue to avoid general practice as a career, and the whole system will end up being run by nurse practitioners.
The proposal is a good one especially as it s designed to address the specific needs of people with chronic conditions and/or some form of disability. There are a multitude of forms of assistance available for the latter but they are scattered over a wide range of bureaus and often involve immense form filling for marginal discounts and rebates. Something like a one stop shop, in this instance a doctor to enrol you as suggested, would be a boon. The case of children with autism is a good example. It appears that one solution frequently adopted to the lack of integrated services is often for one parent to cease work and retrain as a carer for the autistic child. A lot of what they do appears to be seeking assistance and filling in forms for rebates.