Ruth Armstrong: Meeting need

WHAT mental image do you have of a “frequent attender” in general practice?

An elderly person whose multiple morbidities and medications prove hard to stabilise? A patient with an atypical presentation who bounces backwards and forwards between investigations and specialist visits in search of a diagnosis?

A sad and angry young adult who can’t quite form a therapeutic relationship with the mental health team and keeps returning? A toddler whose young, inexperienced parents need reassurance, advice and monitoring?

A person who is dying and requires frequent adjustments to symptom control medication? A drug-seeker who does the rounds of the local GPs hoping for an unguarded moment?

Reading a report from the National Health Performance Authority (NHPA), released last week, brought these and many more scenarios to mind.
    
The report used data from the Medicare Benefits Schedule and the Australian Bureau of Statistics patient experience survey to reveal the extent of frequent use of general practice in 2012‒2013. It explored some characteristics of people who visited a GP more often than average. The two top attendance groups were “very high” (more than 20 visits in the year) and “frequent” (12‒19 visits).

Jointly, these two groups comprised 12.5% of the population, with the report showing that they included “a broad mix of people from different age groups and socioeconomic backgrounds” but that very high and frequent attenders were “more likely to be older, live in areas with the most socioeconomic disadvantage and have the lowest rates of private health insurance coverage”.

They were also more likely to report poor health and a range of chronic conditions, and to have presented to a public hospital emergency department.

The report suggests that, to a large extent, frequent attendance represents met need — something GPs probably already know. But meeting this need has its price.

On the day of the report’s release, health economist and policy expert Stephen Duckett wrote in The Conversation that while these two groups jointly comprised only 12.5% of the population, they accounted for 41% of Medicare out-of-hospital spending on services such as specialist attendances, diagnostic testing and enhanced care items.

There are a few red flags in the data, such as that very high attenders saw an average of 4.8 different GPs in the year examined, with many seeing more than five, raising questions about whether this is leading to duplication of services, inefficiency and waste.

RACGP president Frank Jones shared Duckett’s concerns, telling the Sydney Morning Herald that these were the very patients who would benefit from “an ongoing relationship with a specific regular GP”.

The report provides an interesting backdrop to a study published today by the MJA that is the subject of our lead news story.

The study used data from the Bettering the Evaluation and Care of Health (BEACH) program to calculate the projected impact on general practice of the federal government’s freeze on Medicare rebates.

The freeze, which applies to all services, is currently set to extend until July 2018, by which time the authors calculated it would equate to a 7.1% reduction in GP rebate income. Just to recoup this loss, GPs who continue to bulk bill concessional patients would need to charge non-concessional patients about $8.50 for a standard consultation.

However, if GPs decide to recoup the costs, correlating this study with the NHPA data, it seems likely that for many patients the rebate freeze will impede much needed access to general practice services.

Federal Health Minister Sussan Ley has inherited this arbitrary policy response to an ideology of cost-containment in health care but, this week, she reaffirmed to MJA InSight that the government had “galvanised” its resolve to consult on any future measures to ensure they had broad support from health professionals, patients, the public and Parliament before being implemented.

It is great to see the data becoming available to help us explore the complex challenge of meeting patient need while avoiding waste and duplication in health care.

GPs, who have been picking up the slack of unmet patient need for too long, have much to bring to this conversation.

Dr Ruth Armstrong is the medical editor of MJA InSight. Find her on Twitter: @DrRuthInSight