Fund-holding and voluntary patient registration (vicdoc)

 

The Rudd Government’s plan for fund-holding ‘will offer Australians with diabetes the option of signing up with a GP practice of their choice.’  Under this plan, the patient will elect to be treated at a particular practice, and this practice will become responsible for managing their care. This would include organising additional services for the patient, such as referrals to a dietician or physiotherapist. The practice will be paid, in part, on the basis of their performance in keeping their patients healthy and out of hospital.

 

This will happen through yearly one-off payments of around $1,200 a year to practices for a specific patient to cover the ‘day-to-day costs’ of GP care. The Government will also provide payments of around $10,800 a year for the average general practice, paid in part on the basis of performance in providing better care and improving health outcomes.

 

AMA Victoria held a GP Forum on the issue of patient registration and fund-holding on 16 October 2009. Three speakers spoke for patient registration, and three against.

Consensus among those who opposed patient registration was that voluntary patient registration was the first step to mandatory patient fund-holding. The patients’ ability to choose a doctor was noted as valuable, as the market could drive good patient care. Others against the proposal of patient registration noted the dangers of government gaining more control over patient care.

 

Speakers for the proposal of fund-holding and patient registration noted the value of coordinating patient care, the need to better utilise the information held in general practice, the care and cost pressures from an ageing population, and the ability of patient registration to enhance the capacity of general practice.

 

AMA Victoria policy over many years has opposed fund-holding, on the basis that the cons outweigh the pros. The AMA view is that fund-holding has many negative implications for GPs and for the distribution of medical care. In an attempt to operate within capped budgets, GPs could be forced to use a range of undesirable methods to treat patients equitably (see below).

 

 

 

 

Operating within pre-determined budgets could force GPs to use a range of undesirable methods to manage their funds, which could include:

 

·         Introducing rationing or eligibility criteria for care (especially for long term care of the chronically ill).

·         Discouraging service utilisation (e.g. shorter hospital stays, fewer specialty services, less use of expensive technologies).

·         Selective registration (also known as cream skimming or cherry picking) on the basis of risk (preference for lower risk groups or patients with private health insurance) resulting in a built-in advantage

for practices situated in more affluent areas. Selection could also operate by restricting the range of services available (eg. rehabilitation, disability).

·         Substituting ‘cheaper’ options for medical services (i.e. removal of procedures from doctors in favour of other professionals such as psychologists and optometrists).

·         Reducing expenditure on capital costs.

·         Reimbursement on the basis of patients’ potential risk. This process of risk selection, known as medical under-writing, discriminates against the poor and unwell.

 

From the Australian Medical Association’s Position Statement on Fund-holding (2004)