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14 May 2018

BY DR RICHARD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE

Recent comments by former AMA President Dr Steve Hambleton, who led the Government’s Primary Health Care Advisory Group, have highlighted that the Government’s Health Care Homes Trial has hit troubled waters. It is no secret that practices have dropped out of the trial and patient sign-ups are well below target.

While supporting the concept of the Health Care Home, the AMA has had concerns with the implementation of the trial from the very start. It seems that these were not misplaced, and it is hard to see how problems with the trial can be turned around – even with the goodwill of the profession.

The target of 65,000 patients for the HCH will not be reached any time soon, which has serious implications for the collection of base line data. This work is fundamental to the evaluation of the trial and is supposed to be completed by 30 June 2018. On current indications, it is hard to see how this baseline data could realistically be a valid foundation for any comparison of future outcomes.

So, what are the barriers affecting the trial’s full implementation and threatening the validity of its evaluation?

Well, in the AMA’s view, the funding provided under the trial is inadequate. GPs are being asked to be innovative and pro-active, and to deliver a greater range of services to patients with no additional funding.

In a move away from fee for service, practices will receive a bundled payment for this care to divide up with their GPs and other staff.

This represents a new way of doing business for most practices, with the potential for disputes and extra compliance costs. Contractual relationships also become uncertain. While the Government has released accounting and taxation advice to the effect that HCH funding will not affect the existing relationship between practice and practitioner, many GPs remain wary of the potential consequences.

The unavailability of the risk stratification tool at the outset of the trial made it difficult for practices to undertake an accurate cost benefit analysis before signing up. Practices need to understand the implications of the move to bundled payments, including the likely costs of caring for eligible patients and how this might compare to the funding being provided by the Government.

While the new bundled payments system being trialled allows GPs to bill the MBS for care that is not related to a patient’s chronic condition, the distinction is often unclear. Does a wound care consultation relate to a patient’s underlying chronic condition or not? Everyone is aware that the Department of Health is monitoring billing practices under the trial and no one wants to fall foul of billing rules.

Being a Health Care Home, effectively involves a systemic whole of practice change. Some of those practices involved are already well down the path of patient-centred, multidisciplinary team care, under-pinned by data-driven quality improvement. Others are not, and significant changes are required to be in that space.

Other issues include shared care plans. There are concerns about patient privacy because of the requirement for the whole health care team to be given access to the entire shared care plan. This is problematic if a patient does not want their podiatrist knowing they have a mental health condition.

We also know that general practice is one of the most computerised professions. However, that is not necessarily the case for other health professionals within the care team – making use of a share care plan something that is outside their systems capability and their normal clinical workflow. Getting engagement in any activity outside of clinical workflow is going to be difficult, particularly where funding does not support it.

Under the bundled payment model, we also know that there is pressure on practices to devolve work to the least cost provider. For many GPs, this is a very significant issue. While team-based care is now part of everyday general practice, the fear of effectively losing meaningful responsibility for the care of a patient is a real concern for GPs.

The Medical Home model of care is a good one and still represents the way forward for general practice in this country. It revolves around a GP led model of care and, with proper data collection, is a vehicle that can demonstrate the value of general practice in the health care system.

However, the current HCH trial is clearly struggling and unless it is given more time and additional investment, its results could well spell the end of what is conceptually a very sound health policy.


Published: 14 May 2018