The beginning of the end for Medicare?

General practitioners face an unprecedented performance shake-up under the Federal Government’s National Health and Hospitals Network with the introduction of performance payments for keeping chronically ill patients out of hospital and the prospect of primary care league tables, writes AMA Victoria president Dr Harry Hemley.

Last month’s Federal Budget confirmed the introduction of the voluntary enrolment scheme for patients with diabetes. From 2012 patients will be invited to sign up with a medical clinic of their choice. Practices will be paid up to $1200 annually for each diabetic patient they sign up, plus an initial $1500 practice sweetener.

The practice will then become responsible for managing the patient’s care and will be eligible for annual payments worth up to $10,800, depending on the number of patients they enrol and, in part, on the basis of their performance in keeping chronically-ill patients out of hospital. 

For the first time since 1 February 1984 some Australians will be seeing their family doctor without the right to a Medicare rebate. After 26 years, this universal aspect of Medicare is being eroded in favour of patient registration and paying for performance.

The government’s proposal, as it stands, just covers people with diabetes but the Prime Minister and Health Minister have indicated this is a pilot program likely be expanded to encompass other chronic conditions in future.

“We have outlined our plan to start paying for better health outcomes rather than just one-off visits to doctors and specialists for patients with diabetes,” said Ms Roxon at the Australian Practice Nurse Association Conference in Melbourne last month. “I am pleased that we’ll have more to say on our other directions in primary care very soon, which will build on these significant reforms.”

The National Health and Hospitals Network’s performance framework will be monitored by the yet-to-be-established National Performance Authority, which will also oversee hospital performance. The primary care data will be used to produce performance reports called Healthy Communities Reports, but the government is yet to reveal how details of how the reporting system will work.

The Healthy Communities Reports will include coordination measurements, such as the number of avoidable hospital admissions, prevention trends, local and regional information on preventive risk factors, access to GP services, and after-hours care. The government says the details of what will be measured and how it will be reported are yet to be developed but will be done in consultation with doctors and other health professionals.

It is unclear what role the recently announced Medicare local primary health care organisations will play, or even if the reports will be made public. Minister Roxon has not ruled out the possibility of creating regional or practice-based league tables.

Pay for performance is not a new concept for Australian GPs. The General Practice Immunisation Incentive Scheme (GPII) was introduced in 1997 to reward GPs with bonus payments for promoting, providing and monitoring childhood immunisation service. Since 1998, Medicare’s Practice Incentives Program (PIP) has been paying practice bonuses to thousands of Australian practices for meeting, or working towards, practice accreditation standards.

The difference between the existing programs and the diabetes plan is that under GPII and PIP, GPs are paid for providing services. Under the diabetes plan, the government wants to pay for patient outcomes, which won’t always reflect the quality of GP care.

Proponents of performance payments argue that the end result is the key. The object of health care is to make people healthier, so doctors should be paid for results. This was reportedly taken to the extreme by Arabian royalty in the middle ages, where the princes only paid their doctor when they were well. If they were sick, the doctor was not doing their job well enough to deserve reward.

Critics of paying for performance outcomes make the point that a doctor can recommend a course of action, but successful outcomes rely on the patient. For example, doctors are likely to recommend that all of their patients quit smoking, yet one in six adults still use tobacco on a daily basis.

There have been analyses of pay for performance regimes that have noted other possible deleterious effects. Pay for performance has been cited as: 

• Encouraging doctors to avoid sicker patients who are less likely to achieve the outcomes — often the neediest people in the community.

• Causing doctors to neglect the types of care for which there are no reward. This is a common complaint about KPIs in the Victorian hospital system — what gets measured gets done.

• Increasing red tape, as reporting on performance takes time away from patient care.

• Decreasing internal motivation, as external motivation is imposed by the performance targets.

Design is key for pay for performance regimes. Victorian hospitals have already seen scandals and data manipulation by hospitals overzealous to meet KPIs, which have actually resulted in poorer patient outcomes.

While general practice does not have armies of administrators putting pressure on clinical staff, there is still the potential for pay for performance to do more harm than good.

The AMA has put an alternative proposal for chronic disease management to the Federal Government based on the existing MBS structure and some key improvements. Under the plan, patients with chronic conditions would have access to a broader range of MBS-subsidised allied health services, and excesses of MBS red tape would be reduced.

Our plan ensures that patients do not lose their entitlement to a Medicare rebate and that funding arrangements do not interfere in the doctor-patient relationship. It means that patients would have more choice and greater control over decisions about their health care, and it provides patients who have multiple conditions with improved access to GP-coordinated care services.

Unlike the government’s diabetes plan, the AMA alternative would allow patients to receive care based on their clinical needs rather than a predetermined capped budget.

The AMA plan means that patients would have more choice and greater control over decisions about their health care. It targets the sickest patients with multiple co-morbidities, allowing them improved access to a range of health services.