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AS the general practice landscape in Australia shifts from small or solo practices to larger group practices and corporate models, the elephant in the room is whether quality of care is affected by corporatisation of primary care.
A Perspective published in the MJA highlights a need for more research to ensure quality and continuity of care aren’t being sacrificed.
“At present, 2% of Australian general practitioners work in solo private practices, while 20% of full-time GPs and 33% of part-time GPs are employed in large practices with six or more GPs. Practice ownership levels have changed as well. In 2020, 25% of Australian GPs were practice owners, a decline from 35% in 2008,” the authors wrote.
The article highlighted that although there isn’t significant research in Australia to determine whether care is better or worse in privately held practices, there also isn’t any evidence that it’s better.
Professor Caroline de Moel-Mandel from La Trobe University, one of the MJA article authors, told InSight+ in an exclusive podcast:
“Unfortunately, there isn’t enough research around. We have some from overseas studies which showed that the quality of care is worse in non-traditional provider practices, relating to patient experience, efficiency of care, access and clinical effectiveness. But only a few Australian studies have looked into that and up to now, we haven’t found any difference.”
The MJA authors wrote that there were four areas in which the size and model of GP practice ownership had impact:
- impact on access to care – “Access may be affected when multiple smaller practices conglomerate into larger, more centrally located practices, especially for people residing in regional and remote areas where there are already fewer GPs per person”;
- impact on continuity of care – “In larger practices, the ‘usual GP’ was often replaced by ‘usual practice’, resulting in patients consulting GPs they had never met before”;
- impact on quality of care – “Research suggests that the quality of corporatised GP services may be worse compared with care delivered by traditional providers”; and
- impact on health expenditure – “It has been argued that the observed increase might be associated with the practice of overservicing to meet income targets, or with GPs over-referring to commercially related and co-located services”.
Of particular concern is primary care in rural and regional areas.
“These practices are now clumped together, and it makes travel time longer for these people and access more difficult,” said Professor de Moel-Mandel. “Due to the consolidation of these practices, it’s also led to a reduction of bulk billing and increase of out-of-pocket fees.”
With 60% of non-owner GPs “not at all interested” in becoming practice owners in the future, it looks likely the trend towards corporate ownership will continue.
Why isn’t GP ownership attractive anymore? The reasons are complex.
The most touted argument is work–life balance. General practice is a great, family-friendly option for many young, and particularly female, GPs, with part-time options and job-sharing popular. Many see practice ownership as being too all-consuming while juggling other responsibilities.
Dr Katrina McLean, a GP and co-moderator of the GPs Down Under Facebook group, told InSight+ the work–life balance question was one consideration when she contemplated practice ownership, but it wasn’t the only factor.
“Could you take on practice ownership and work part-time? Not easily,” she said.
“I often read that GPs are choosing not to own practices because of work–life balance. I think there are a lot of GPs out there who, with the right support, would genuinely be very interested in practice ownership. It’s complex and I don’t think it’s as simplistic as the work–life balance.”
According to Professor Danielle Mazza, Head of General Practice at Monash University, GPs interested in practice ownership would need help in all areas of running a business as it was not what a GP was trained to do.
“It’s a difficult transition,” she said. “The complexities of running a business are enormous. It’s not just dealing with billing but also human resources, quality control, protocols, accreditation. In order to be successful, a practice has to have good governance and a good skill set in management.”
Another area of concern is financial.
“If you think about the length of time doctors are in training, they come out in their late 20s or early 30s at a time when they want to start families or consolidate their families and buy houses,” said Professor Mazza.
“Then you’re asking them to buy into a practice with a significant financial overlay.”
It was this financial outlay that also put off Dr McLean.
“When I sat down and went through the numbers, the risk in doing [becoming a practice owner] was immense. For me, it wasn’t a viable option. Financially, it’s incredibly difficult,” she said.
Women, who are still battling with the gender pay gap, face particular challenges.
“We know there’s a significant gender pay gap within general practice as it is,” said Dr McLean.
“I’d suspect that would have to flow through for the decision making for female GPs. It seems to be harder.”
According to Dr McLean, one way to encourage GP ownership would be to increase funding for general practice.
“If you’re running a business, your costs are going to be increasing year-on-year,” she said. “Funding keeps being eroded from primary care. If I was feeling more secure about funding coming into general practice, it would help to have the confidence to make that decision,” she said.
Professor Mazza said there needed to be more research before any incentives could be considered, and one focus should be on what’s going on in the practices we already have.
“The focus should be quality of practices, and the pandemic has thrown a spotlight on issues of governance in practices,” Professor Mazza said.
“The ability to respond quickly in emerging issues such as the lockdown, the move to telehealth, the introduction of electronic prescribing and now the vaccination rollout – that all requires very good and nimble governance within a practice. GP ownership in practices might have more of an influence with those types of issues,” she said.
If the corporation which owns the practice doesn’t consider the views of the GPs, there can be concerns about patient care – something Dr McLean says she has experienced.
“In some large corporates, you work individually in separate rooms. Unless the corporate values clinical governance, I think there’s risk with that. Looking at the bottom line, there isn’t necessarily the funding there to have clinical directives and GPs fitting into leadership roles in corporate practices. That’s something that is challenging. Even the value of patient care can be more difficult to achieve,” she explained.
However, Dr McLean admitted it depends on the culture and the values of the corporation, and she’s worked in other corporate environments that have a completely different view on patient care.
Ultimately, the experts agree, we need more research to determine the best outcomes for patient care.
“Continuity of care is important and is an area where we need more research. If we look at the trajectory of where [GP ownership models] are going, I can’t see anything changing without a significant alteration around the funding and investment in general practice,” Dr McLean concluded.
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I see a parallel here – the communist revolution! The ‘means of production’ have been taken away from us doctors. And we are doing a proletarian revolt! The ‘staff specialist’ model of in hospital specialist – aka the time sheeted doctors pay – is a social rot! The same is happening in GP land. The staff specialist model is a systematic destruction of meritocracy where groupism breeds. They resort to anticompetitive practices by ring-fencing, in-breeding and overt corruption. If you are a true doctor you must become either a Locum specialist or an independent solo GP! Or you join the phylum invertebrata! What a social ruin the corporate culture is creating? How come ‘CEO’s and their cronies are ‘playing doctors’ by proxy! Where is the ‘regulator’ when we need to keep these corporate quacks in check?
Family Practices are not viable until get funding to run and get good workforce.
The essential of research should answer the following:
1) What is the length of time that GPs stay at one corporate practice?
2) How many “sessions” do GPs do at the one corporate practice? If the GP appears on the letterhead but is only there once a week, is there a serious argument that continuing care is being provided?
The essential ingredient of the family doctor / patient relationship is continuity of care which not only means the same doctor but the same receptionist – all part of the team!
As one of the 2% of GPs in solo private practice, my patients see the same person 100% of the time. It is a wonderful and satisfying life.
Even in the UK there are solo practices. They bandied together to form a group, Single Handers In Trouble. Great idea. Terrible acronym
With fond memories going back 50 years, the family GP was an essential and much loved and respected pillar of society. The doctor or a practice colleague would do a home visit at any time of day or night if needed; knew the patient and family well; would visit regularly to provide ongoing care during a prolonged illness;; and would quickly facilitate hospital care only if unavoidable. One does not need research to know what we have lost from allowing the once independent profession of medicine to be controlled and dictated to by a plethora of third parties all with their non-professional agendas, be it politicians, for profit insurers, regulators, or corporates. Ambulances ramping at ED’s and escalating demand for hospital beds are but one symptom of governments inadvertantly facilitating the demise of the family GP.
Universal bulk billing saw the beginning of the demise of the opportunity for GPs to be able, either in solo or small group practice, to build a practice which provided an asset to sell on retirement. Nothing will focus the mind more than to be personally and financially responsible for building a reputation for competence and the development of a “ successful “ practice. Continuity of care and mutual trust were the keys , which demanded dedication and those who exhibited such features were seen as absolute beacons , by both their patients and colleagues. Then universal bulk billing saw the progressive success of a practice being as much reliant on the relinquishing of billing control, as to clinical competency. The result is clear , everyone has lost out and we have now a whole generation of patients who have never experienced care from a model of General Practice to which , as young GPs we all aspired. So glad that , at least , for the first half of my 50 yrs of practice that I got to experience a level of self respect to which , I think, current young GPs will be sadly denied. Sure a corporate life is more simple and predictable…. was it worth the cost?
Hardly rocket science here.?
Corporatisation of any Health Care Specialty legally demands that the interests of shareholders are pre-emminent.. An EBITDA >15% must be achieved or share price disappears and the executives are out. Then in order of organisational importance follows executive salaries and their generous share options, with recurrent ‘efficiency dividends’ (redundancies) to shore up the market price so as to support the former item. Next follows staffing issues (the enemy) with HR and Finance department to there to bully and deflect. Oh yes, finally the patient (sic customer) appears down the food chain. Of course WE all really care for them, at least in brochures and press releases.
All now follow the USA business model. The Harvard School of Medicine lost out to the Harvard School of Medicine decades ago.
Add to all this private management oversight and control of priorities, the ever ongoing parsimonious Medicare rebate level that both political parties have ruthlessly driven downwards since Medibank 1 in the 1970s and you suddenly realise that it is the government itself that is driving the corporatisation of medicine here. You really have to wonder why any rational young bright student would want to commit their entire working lives to the kind graces of these two predatory beasts.
By the way, it was the Labor Party under Hake/Keating that set the inevitable decline in general practice quality of care and life for both patients and their doctors jn motion when they changed the law and allowed non-medical people or corporations to effectively run practices. They also emasculated the RACGPs at the same time making it effectively nothing but an arm of government policy.
Dr Peter Arnold who comments on this blog occasional predicted this scenario as far back as 1972/3.
American style managed care is certainly to be avoided. As a specialist surgeon the six minute corporate consult referral causes my heart to sink every time.
There are no doubt many reasons we have got to this state but adopting American style managed care is no answer at all, and allowing corporate investors a share of the health dollar does not serve either public government or GP interests.
Corporatisation of medicine is what caused COVID in the first place! Not everything profitable is useful and vice versa. But for corporate feudal slavery, if it is not profitable it is useless! Virology wasn’t profitable for instance. Oh what a shame doctors mortgage their spine and surrender their autonomy to corporate feudal lords!
I can definitely say from working 25 years in Emergency departments that the quality of GP referrals to hospital have deteriorated. Its just too easy nowadays to tell people just to go to hospital.
General Practice is the one area of medical care that has now been devalued over decades and although the formal academic evidence is slim, the anecdotal discussion in the community is significant. As a previous rural General Practitioner (yes, I left along with many others) and a strong believer in that everyone needs a regular family GP, it was an easy decision as to the priorities to choose my own. A smaller group practice (less than 15 GPs), affiliated with University and Medical College teaching programs and is fully accredited. They only bulk bill for specific groups. That does not include me. Yes I pay full fees for a personalised service that I can usually access when I need it and provide me with the confidence that I am a ‘someone’, not the next number. The commodification, consumerisation and corporatisation of health care remains a concern. The devaluation of holistic family based general practice by our funders and our community is tragic.
This relates closely to NIB forming the Honeysuckle Health joint venture with US Corporate Health giant Cygna. The joint venture is currently applying to ACCC for exemption from anticompetitionm laws. The question to be asked of NIB is – what parts of the US Healthcare system need to be imported to Australia??
It’s easy to see the parts that benefit investors and CEOs of health care corporations.
It’s hard to see any part of the US system that offers our patients anything better that what they have.
AMA should be going much harder to educate its members and our patients about NIB’s plans, and pressing NIB much harder to explain to its members what their Health Insurer has in mind for them.
These concerns are validated out in the real world. We have taken on doctors from corporate practices that have administrative staff ringing GPs in their consultations because they have spent longer than the allocated time with their patients. There is one huge infamous bulk billing corporate site in South Australia that is literally “take a number”
and see whoever is available. The resultant lack of continuity, and non-holistic care has their patients being dreaded by the local Emergency department staff.