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THE solution to reducing the amount of time Australian GPs spend on non-billable work – which is costing them between $10 000 and $23 000 a year each – is to change the funding model itself, experts have told MJA InSight.
According to research published in today’s MJA, 69.5% of GPs reported providing non-billable care outside patient visits. Reasons included arranging tests and referrals, consulting specialists or allied health professionals, medication renewals, and advice and education.
The study found that a GP will have about 620 occasions per year where they spend an extra 10 minutes outside of consultations on various aspects of patient care.
The financial cost of this is significant, the authors wrote.
“Were this care claimable through Medicare, this time would return between $10 000 and $23 000. For some GPs, the amount foregone would be much higher than this average,” they estimated.
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President of the Royal Australian College of General Practitioners (RACGP), Dr Frank Jones said the research findings did not come as a surprise.
“It reinforces what GPs have known for a very long time, that there is a multitude of things we do outside face-to-face consultations in general practice.”
These non-billable hours reflect a problem with the current fee-for-service Medicare charging model, he told MJA InSight.
“Fee-for-service doesn’t work for people primarily with chronic disease, which is more of what primary practice has to deal with.”
About half of all Australians have a chronic disease and about 20% have at least two, according to statistics from the Australian Institute of Health and Welfare.
Professor Glenn Salkeld, Executive Dean of the Faculty of Social Sciences at the University of Wollongong agreed.
“We need to move away from a system based predominantly on a fee-for-service system to one in which there is reward for the care of all aspects of a patient’s health and wellbeing as well as rewarding the transactional aspects of care (delivery of actual services and consults). If you only reward activity then activity is what you will get.”
One of the study authors, Associate Professor Graeme Miller, told MJA InSight that no country has a perfect system, but that a mixture of blended payment systems with fee-for-service was the way of the future.
“I see an evolution towards a payment system with an increasing amount of block payments,” he said.
He highlighted the Danish primary health care system as being one of the better models, using a mixed capitation and fee-for-service system.
Professor Salkeld said: “A blended system of per capita (patient) based funding and fee-for-service would seem desirable if it provided incentives for prevention and for the patient to be supported in managing their own health.”
However, he was adamant that changing the payment model needed to be a genuine exercise in improving care, not simply a way to reduce expenditure.
The RACGP has proposed a Medical Homes model as a potential pathway for improving health care. This model would involve patients being registered to a particular practice, allowing them to better manage their care.
Although this informal registration already occurs – 96% of patients and 98.6% of patients over 65 already have a practice they visit regularly – this model would formalise the approach and potentially make it easier to introduce a new payment model.
Similar to this design is the Health Care Homes model for chronically ill patients announced by the Turnbull government in March.
This new payments system is set to be trialled and evaluated from 1 July 2017 to 30 June 2019 and will cover 65 000 chronically ill patients.
It will include the introduction of upfront and quarterly bundled payments for GPs who are caring for chronically ill patients. However, many say the $21 million allocated for the trial simply isn’t enough, particularly as it’s not directed at services for patients.
AMA President Dr Michael Gannon warned in June: “At a time when medical practices are already struggling with the effects of the Medicare rebate freeze and other funding cuts, the government seems to expect that GPs will be able to deliver enhanced care for patients with no extra support.
“This approach simply does not add up, and will potentially doom the model to failure. GP engagement is vital if these reforms are to be implemented.”
Further, there are fears the trial won’t be designed or evaluated properly.
“What we need are proper guidelines, set up properly with a proper appraisal at the end to see if they work,” Dr Jones said.
The recent announcement of the closure of Sydney University’s BEACH project and Primary Health Care Research and Information Service exacerbated fears of a future of insufficient research into these vital primary care trials.
“There is a huge threat to GP research because of the demise of these two organisations. Only about 2% of research grants from the NHMRC goes into general practice yet we are seeing 85% of the general population every year. It doesn’t square off,” Dr Jones said.
Professor Salkeld agreed.
“We cannot spend millions on GP care without knowing what’s going on at a level of detail greater than being captured by the payment system mechanism/database.”
Despite the financial fears of the future of general practice, there is no lack of passion from the staff working in the field.
Associate Professor Miller said he may have to work on an honorary basis when there is no BEACH funding.
“It’s all about making a difference,” he said.
Dr Jones said that after presenting at a recent student conference, he was overwhelmed by the response from the medical students who, despite hearing the pitfalls, were still convinced about their path into general practice.
“General practice is such a wonderful, wonderful part of medicine. The special gift of general practice is that you provide continuity of care and you get to know your patients over a period of time. You make a massive difference to peoples’ lives.”
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Goodness me, what has the profession been reduced to by the iniquity of bulk billing?! The way I see it is this, as quaint and as old fashioned as it may seem. I charge a fee, a fair fee that will earn me a reasonable income and being a professional fee, it includes a moiety for work that needs to be done behind the scenes, checking and collating results and musing over their implications, writing the odd referral and or scripts. This is a contract between myself and my patient. It is a direct connection and line of responsibility between us.That patient has a contract with their insurer, by compulsion with the government run Medicaire. That is the way it is in my practice and has always been. I don’t get blamed for the huge gap between my fee and the Medicaire rebate. Patients can easily see what has happened over the years and the government gets the blame which is as it should be.
Moving to any other than fee for service models will end up in a US style managed care system in which, in order to contain costs, decisions about investigations, treatments etc will ultimately rely on the approval of a health economist deciding what can and can’t be done using an “evidence based” algorythm that has nothing to do with the unique (n=1) individual that you are trying to treat, their family circumstance, their comorbidities and even their medications.
I agree that as doctors we do a lot for our patients without charging for that activity, incl calls to specialists etc.
this is why a standard consultation is not meant to be 8minutes on average. Medicare allows for upto 20minutes to be spent, ie the extra 10minutes the article talks about. Sadly, we all do work outside the consultation, but if we wish for a different system, I think it has be pointed out, that there is no perfect system. If outcome based system comes in, how do we ensure that we only see the compliant patients so our outcomes are ‘great’.
It’s not only GPs ! As a surgeon in private practice I spent countless unpaid hours talking to patients on the ‘phone, writing letters and certificates on their behalf , clarifying results with laboratories, talking to colleagues on their behalf, calling relatives etc etc., not to mention the “swings and roundabouts’ of postoperative care. I was bemused and a little envious to find that that lawyers charged for everything, from phone calls right down to photocopying— ” billable hours” ( or minutes in many cases ). I am not sure Medicine can adopt this model but the Medicare schedule should include provision for work extra to the consultation or procedure, provided it is carefully documented ( as lawyers do)