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There are concerns that a voluntary patient enrolment program in Australia could lead to a capitation funding system similar to the one used in the United Kingdom.
At last week’s Budget, along with $3.5 billion earmarked for general practice, the government announced the MyMedicare program, which introduces a voluntary patient enrolment (VPE) option for patients.
Although general practice still operates largely on a fee-for-service model, there are those who are concerned that VPE is too close to the funding system of capitation.
Australian primary health care operates on a majority fee-for-service model, in which patients choose a GP for an appointment and Medicare pays the patient a subsidy. Capitation – the system under which the United Kingdom’s National Health Service (NHS) operates – sees patients register with one GP and the government pays a capped amount for a year’s worth of visits to the clinic. To remain eligible for payment, the clinic must meet a set of key performance indicators (KPIs).
GPs from the UK say that the NHS is buckling under a system of capitation.
Dr Chris Irwin is a GP who ran for the office of Royal Australian College of General Practitioners (RACGP) President last year on a platform opposing capitation. He is concerned VPE will ultimately be bad for GPs and the doctor–patient relationship.
“The buzzword for capitation is [VPE],” Dr Irwin told InSight+. “With VPE you get funded, with a lot of strings attached, directly from the government. So, the government is now your client as opposed to the patient.”
“VPE is part of a blended model, where theoretically we keep our fee-for-service … and we also get an extra payment on the side [for patient enrolment]. My primary argument is that this blended payment model is the thin end of the wedge, and that VPE will become anything but voluntary, because eventually you need that money to survive as a medical practitioner,” Dr Irwin said.
Dr Irwin believes fee-for-service will ultimately be less affordable than it is currently for low income Australians, and that the KPIs will become the focus of primary health care.
“You start off with easy KPIs. Everyone’s happy with extra money floating around. People get hooked onto the system and then every year they tighten the KPIs, making it harder to achieve those hurdles to reach the payment thresholds,” Dr Irwin said.
Are voluntary patient enrolment and capitation the same?
The Australian Medical Association (AMA) supports the MyMedicare announcement, citing its Modernise Medicare campaign. AMA President Professor Steve Robson said that the AMA opposes capitation but supports VPE.
“The AMA supports [VPE], but only as a mechanism to help ensure a stronger linkage between a patient and their usual GP, and establish a basis for extra funding,” Professor Robson told InSight+. “Experiments like Health Care Homes have shown that capitation does not work in the Australian context.”
“Many of the challenges facing GPs in the UK are also felt here, [such as] the increasing health needs of an ageing population with more multimorbidity. Regardless of the funding model, the challenges facing primary care over the next decade are real,” Professor Robson said.
“Capitation is not the answer, but VPE is not capitation.”
The United Kingdom and the NHS
InSight+ spoke with one GP and clinic business manager formerly working in the UK, whose spouse is also a GP. The couple emigrated from the UK to Australia to avoid capitation. (The GP did not want to be named in this article.)
“The workload kept on increasing year by year, and, often, the expectations of what GPs had to do also kept on increasing, but the remuneration was the same. To perform more, we had to employ more staff, and the expenses kept on increasing. The eight- to ten-hour day ended up being a 12-hour day. It was just not feasible,” the GP told InSight+.
“You’re just really ticking boxes and doing paperwork when you should be spending time with patients.”
InSight+ reached out to the RACGP and did not receive comment in time for publication.
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Very pleased to see you refer correctly to Medicare rebates as being payed to the patient. Not the more common and misleading comment claiming the Medicare benefit is paid to the Dr.
I escaped the UK NHS 35 years ago for this exact reason – capitation does not work. GP’s were burning out then. My average working week was 120 hours and unsustainable. Beware of this very surreptitious process. We have seen government control gained by computerization over last 25 years here in Australia. Learn from lessons of the past and other countries experiences.
The thought of following the U.K. with the introduction of capitation is frightening.
Any system can be gamed and will be. Under capitation the game is to have as many well patients on your books as possible. Many years ago i worked in the UK for a few years and two of the specialist consultants had been appointed as GPs for live in staff at the hospital, these staff being mainly young people. As the junior doctor for one of these, I was told it was part of my job to do the clinic. When I became mildly unwell, he handed me a bit of paper to enrol as his patient! Some things in medicine may be treatable on a capitation fee basis, but usually fee for service is usually the fairest way of paying for medical services.
The problem in the funding of health services is that the requirements for qualifications have increased, new and expensive treatments have arrived and people are living longer and the government doesn’t want to pay for them. When the NHS was set up 75 years ago, cradle to grave health care was promised, but people undertook this journey much more quickly and cheaply than nowadays. Pay for what you promised! In Australia the NDIS reparented a victory a victory of Allied Health over doctors and nurses and offered social welfare programs instead of treatment programs, offered free money to both allied health and support workers, promised the clients the earth without budgetary limits. Now the government has worked out that it has to pay for all this.
If VPE is not capitation, but will help GPs, how? Will the Govt give money for enrolments with no strings? The idea of “budget holding” based on UK models goes back at least 20 years here, and were rejected – for the same reasons outlined in this article, ie, govts want behavioural change, outcomes, and KPIs. What govt wants doesn’t always align with professional ethics and values.
VPE is not a funding system as the Colleges Health economist noted at the October summit. I do believe Dr Chris Irwin was there and hence he should know that. Fee for service is wholly supported as the basis for health care by the RACGP.
The government must face the electorate as to how much they will subsidise health care and to whom. The current system has failed the inverse care law. The most needy and greatest of health needs have the least ability to access care. This group have also the greatest burden of illness. As a society ethically we must decide how to spend health dollars wisely. A full fee for service without appropriate indexation fails this group of people. As we have seen especially rural folk have poorer access and poorer outcomes. Workforce is a critical issue and any funding system must be as attractive to new graduates as that for the procedural specialties.
(A thought experiment —Indeed why not make mental health care work as richly rewarded as let’s say Urology? )
Capitation is as suggested above a “capped level” of funding with terms and conditions that in the case of the NHS has increased compliance and eroded the profession. It’s a salient lesson of where not to go.
Whilst fee for service must remain as the centrepiece it must also have an independent pricing authority to index properly to the cost of service. Otherwise one could argue that during the freeze it was indeed capped yet tied with increasingly nonsensical terms and conditions. A form of proxy capitation perhaps with the Medicare freeze for those in the poorest socioeconomic areas. A political lever that judging by Jaqui Lambies recent ignorant (and appalling) comments should not be in the hands of those who wield power unwisely.
Every part of healthcare dollar spend will have a contract. Including even the cash part of the gap fee. It is unreasonable to think that there is an open bucket of money somewhere.
VPE as yet has no great visibility of terms and conditions.
Like all initiatives in health economic systems there will be unintended consequences. As there is with every form of health subsidy. Block funding also can fail-as well as it can support. There can be cronyistic applications of successful tenders which must be protected against.
Humans need always guard against their own base impulses with good governance.
At this point it seems to me the Government has attempted to address the inverse care law (in part) with the triple bulk biking incentive and with the long level E. VPE has no Ts and Cs yet and I would think are still under negotiation. They need to be continually reviewed to fulfil the Quadruple aim principles
Rather than a two tier system there will be multiple systems of funding which is from my understanding the best evidence in health economics. For physicians and patients.
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What is becoming an obvious is we do need an independent pricing authority to manage rebates. We could also review the safety net.
Philosophically we need to understand as I have said elsewhere the equipoise between equality and equity.
Whether the wealthy suburbs should have the same system as the least wealthy. The argument is where on that pendulum do any of us sit?
Finally GPS are rightly concerned about the blunt instrument of punitive compliance because no matter the funding this will kill off the pipeline at the beginning middle and the ends. We need to see more natural justice there to ensure proper process for inadvertent use or vexatious complaint compared to egregious issues.
GPS and medical professionals shouldn’t need a law degree to interpret an overly regulated Medicare or billing schedule.
Lots to continue to reform. Reform without reinvestment is just redtape I have said to every health minister. With some long overdue reinvestment at least it seems we are beginning the reform.
VPE is not capitation whilst fee for service survives. It’s not even clear what it is yet. Yes terms and conditions need regular review. We need independent oversight to assist with rational reform.
I’m interested to see what are the next steps. We’ve at least had a step which is more than General practice has had in decades.
Be cautious and curious is my recommendation.
Of course it will! It’s so obvious. If you make fee for service bulk billing unviable and then offer a package to survive, doctors will grab the life raft.