Restructuring primary health care in Australia
by Stephen Duckett and John M Dwyer
Published by the Medical Journal of Australia, Monday 21 November 2016
When appropriately resourced, medical homes can deliver the system-wide beneﬁts of truly integrated primary care.
For patients with chronic and complex conditions, optimal care involves a range of clinical skills other than those provided by doctors (eg, a social worker, a clinical nurse specialist or a home care team), some of which are generally not available through Medicare. Patients experience fracturing of their care — such as the need to obtain referrals to consult other health practitioners — and signiﬁcant out-of-pocket expenses, on which Australians spent around $27.5 billion dollars in 2013-14.
If both doctors and patients are dissatisﬁed with the current primary care system, what do we wish to offer in the future? Imperatives include a highly personalised service that improves the patient’s health literacy and capacity to better care for themselves and their dependants; continuity of care, important for early detection of problems before they become chronic and complex; the availability of in-house teams to provide most of the services required to efﬁciently manage chronic, complex illness; and care in a community setting for many patients who would currently be sent to hospital.
In the international setting, the evidence suggests that primary care delivered via the medical home model has been most successful in achieving the goal of truly integrated primary care. However, international experience demonstrates that the success of the model requires the availability of a speciﬁc supportive infrastructure.
The medical home
A key factor in the success of this model involves patients identifying with a practice that assumes responsibility for the holistic care of patients. The voluntary enrolment by the patient in a practice of their choice and the psychology associated with it are also important. A sense of belonging to a facility where all health problems can be managed is reassuring and promotes adherence to the advice given. Medical homes foster a culture of partnership and expectation and those enrolled accept the obligation to deal with problems that might produce illness or compromise its management. Likewise, the medical team is responsible for helping their patients to avoid or manage health problems.
The staff of a well-resourced medical home might include doctors, nutritionists, a social worker, various nurse specialists, physiotherapists, occupational therapists and a dental hygienist. For example, in a new suburb with young families, the medical home might have paediatric nurse specialists and pregnancy management experts, but elsewhere with an older demographic, nurses with geriatric and palliative care expertise might be essential.
The exact nature of a given team is determined by the needs of the patients enrolled in the practice. In other countries, the most successful medical homes use electronic health records and offer members electronic connectivity with their team. The Kaiser Permanente group in the United States has turned two million face-to-face consultations with a general practitioner into email-based consultations over the past 10 years to the satisfaction of all parties.
Because of the continuity of care, which involves appropriately scheduled visits, the team is aware of patients whose health is fragile and who need care in their homes or other community setting. Outreach to such patients can markedly reduce deteriorations that might require hospital admission. An effective community intervention in the 3 weeks before patients require hospital care may reduce the number of preventable admissions, which are estimated to be about 600 000 per yearinAustralia.Electronicconnectivity—using platforms such as email, Facebook or FaceTime with patients, their carers and local hospitals — is imperative for this model.
Specialists may wish to afﬁliate with medical homes, but if international trends are followed, more specialists will visit or practice near medical homes creating what has been referred to as the “patient-centred medical neighbourhood”.
The model focuses on mutual respect for the skills of different health professionals and a commitment to the central role of the patient with an emphasis on prevention. After 2009, many countries (eg, the United Kingdom, US and New Zealand) using well-resourced medical homes have reported reductions in hospital admissions of 20-24%.
Introduction of the medical home model to Australia
The Australian government has recently announced plans to establish a trial of health care homes with the aim of “[providing] continuity of care, coordinated services and a team based approach according to the needs and wishes of the patient”. The trial of this model, for which the government is providing $21 million, is due to start in July 2017, and ﬁnish 2 years later. Few details have been provided, but the concept is far from the fully resourced medical homes, whose effectiveness is supported by a strong evidence base. The government’s model relies heavily on some services, such as allied health, being provided outside of the medical home by the 31 Primary Health Networks.
Clinical and consumer champions of the initiative, who have embraced the concept, have convinced others to try the model. Government support, but not imposition, is critical and was a feature of the successful development of integrated primary care in New Zealand. Persuasion not regulations are needed and the old will for some time exist with the new.
In Australia, the introduction of better integrated primary care delivered from well-resourced medical homes as a taxpayer-funded service will require professional, and political support. The Royal Australian College of General Practitioners, the Royal Australasian College of Physicians and the Australian Medical Association have endorsed the need for trials of the model in Australia. The opposition to the move from all Medicare payments being a fee-for-service has dissipated. The model is easily understood by consumers and enthusiastically embraced in many countries.
Remuneration and structure
Remuneration for GPs will occur via a blended payment model, where the majority of income is derived from salaried or contractual arrangements, not fee-for-service payments. Since 2009 in New Zealand, 85% of the public have enrolled in a primary health care program and 85% of GPs are being remunerated via this model. Similar initiatives have occurred in the US since 2011, where in many areas, around 65% of GPs are being remunerated using a blended payment model.
Looking at international trends and the history of provision of primary care by the private sector in Australia, we envisage that most medical homes will be independent, privately run organisations. Many of them may be established as companies limited by guarantee or as not-for-proﬁt organisations.
Consumer involvement will be enhanced by representation on the boards of such companies. Clinicians will be ﬁnancially rewarded for keeping patients healthy. Through their efforts, the clinical team will build up a business that is valuable and their equity in the endeavour improves their overall ﬁnancial wellbeing.
Costing and funding
Pricing skills have been developed in Australia over the past decade to support activity-based funding for hospital care, where the hospital is funded for the casemix of patients it treats. Similar methodology will be needed as we develop new costing and payment systems for primary care services.
There is evidence that the medical home model of care can be adequately funded, with overall expenditure on health remaining in the range of 10-12% of the gross domestic product. Over time, the growth in the amount of funding required will be offset by the increased productivity of a healthier population.
A continuous effort to reduce health system-wide inefﬁciency will be equally important as we move to implement the new model of primary care. Ongoing work of agencies, such as the Agency for Clinical Innovation, to standardise optimal regimens for disease management must continue. Dissemination and uptake of these recommendations will reduce variations in clinical care and improve cost effectiveness. Savings will also come from reductions in rates of hospital admission and specialist visits.
Experience from the implementation of this model, in Australia and internationally, will provide a constant stream of learnings that may lead to reﬁnements of the outlined blueprint. However, there is an acceptance among countries in the Organisation for Economic Co-operation and Development that contemporary health systems need to emphasise and resource both prevention strategies and team management of chronic disease if health care is to be equitable and cost-effective.
References are available online at www.mja.com.au.