Appropriateness of care: why so much variation

Broad descriptions of variation are a useful way of finding disparities, but to generate change they need to be carefully analysed and applied

The Supplement accompanying this issue of the MJA addresses variation in health care delivery as an important theme in ensuring appropriate care across the health system. While all would agree that health care should be provided as and where needed, and that only appropriate care should be delivered, difficulties arise when seeking consensus on what variation is “appropriate” and what should be done about it.

Complex systems are inherently variable. Indeed, a multitude of data shows variation in clinical practice but there is less consensus on its implications. For example, while one focus is high utilisation, there is also an issue with underutilisation, raising issues of equity. Aboriginal and Torres Strait Islander people receive fewer interventions for a range of major health conditions than non-Indigenous Australians; the age standardised rate of coronary procedures is 40% lower.1 Overall, the lowest quintile by socio-economic status of area of residence has 78.8 elective hospital admissions involving elective surgery per 1000 population compared with 91.5 for the highest quintile.2

Geographic variation is the focus of the recent Australian Atlas of Health Care Variation,3 summarised in the Supplement by Buchan and colleagues.4 The Atlas compares extreme high and low rates of interventions, using about 350 areas. An earlier report by the Australian Commission on Safety and Quality in Health Care (ACSQHC) and the Australian Institute of Health and Welfare calculated a systematic component of variation and provided a comprehensive picture covering 60 Medicare Locals, which were in place at that time.5

The two reports focus attention on variation, emphasising unwarranted variation, but crucially they do not define “unwarranted”. While presenting a high profile call for action, priority areas for action are not suggested.

In their Supplement article, DaSilva and Gray,6 noting English experience, point out that an atlas can be used to draw attention to variation, but engagement with clinical and health management leadership is essential for an effective response. Drawing on United States experience, they warn that the transformative promise of variation can disappoint without clinical and political commitment. The authors conclude that:

It is not sufficient to publish an Atlas of Variation … and expect it to have remarkable impact. An Atlas of Variation needs to be an integral part of a larger transformational change program.6

The limited available evidence indicates that public reporting alone has minimal impact on changing clinical practice.7 Change may also be facilitated by considering local factors.8 Atkinson and colleagues identified 13 factors required for system change, including microsystem capacity, credible evidence, engagement, peer support and integration into routine practice.9

In 2016, the Grattan Institute released an analysis of variation in preventable conditions across Victoria and Queensland.10 The report set the bar higher for addressing variation, noting the need for a time series when targeting action. The Institute found that 15% of areas exceeded their variation benchmark each year, but only 5% exceeded it for 3 successive years. It proposed identifying areas showing sustained variation and developing response strategies in consultation with all stakeholders.

Financial incentives are another approach. In the Supplement, Hall and van Gool report disappointing evidence that financial incentives improve quality, and note possible unintended effects through gaming or patient selection.11 Moreover, complex Australian health care financing arrangements make it difficult to share the economic benefits of reductions in practice variations among the various stakeholders. Caution is therefore necessary in considering financial incentives.

A weakness of variation data is that they are always explicable by specific variables, such as patient factors or legitimate process differences. One way to deal with this is to use variation data to identify where change may appear warranted, and then focus on the development of mutually agreed standards of best practice care. Contributions in the Supplement reflect the important work that the ACSQHC has undertaken in this regard: Chew and colleagues describe the process for developing clinical care standards in Australia;12 important examples are provided by Caplan and colleagues (cognitive impairment)13 and Turnidge and colleagues (antimicrobial stewardship).14 However, as noted above, these need to be incorporated into broader micro and macro change strategies.

Wilcox and McNeil argue that clinical registries can play a role in identifying quality interventions and clinical pathways, and indeed the ACSQHC has published guidelines for clinical registries.15 Registries are potentially a link between high level policy and practice variables of interest to a given clinical community. A strategy is now needed to link clinical registries with national hospital data collections, to better inform understanding of in-patient activity variation and performance.

In conclusion, broad descriptions of variation are a useful way of finding disparities, but will not of themselves generate change. To point the way to useful policy change, they need to be carefully analysed and applied.

Variation needs to be addressed as part of the broader quality and safety agenda, where political commitment has been hard won over the past 20 years. Regular, considered reporting of variation may assist, but is not in itself a magic bullet.

Restructuring primary health care in Australia

When appropriately resourced, medical homes can deliver the system-wide benefits of truly integrated primary care

For patients with chronic and complex conditions, optimal care involves a range of clinical skills other than those provided by doctors (eg, a social worker, a clinical nurse specialist or a home care team), some of which are generally not available through Medicare. Patients experience fracturing of their care — such as the need to obtain referrals to consult other health practitioners — and significant out-of-pocket expenses, on which Australians spent around $27.5 billion dollars in 2013–14.1

If both doctors and patients are dissatisfied2 with the current primary care system, what do we wish to offer in the future? Imperatives include a highly personalised service that improves the patient’s health literacy and capacity to better care for themselves and their dependants; continuity of care, important for early detection of problems before they become chronic and complex; the availability of in-house teams to provide most of the services required to efficiently manage chronic, complex illness; and care in a community setting for many patients who would currently be sent to hospital.

In the international setting, the evidence suggests that primary care delivered via the medical home model has been most successful in achieving the goal of truly integrated primary care.3,4 However, international experience demonstrates that the success of the model requires the availability of a specific supportive infrastructure.5,6

The medical home

A key factor in the success of this model involves patients identifying with a practice that assumes responsibility for the holistic care of patients. The voluntary enrolment by the patient in a practice of their choice and the psychology associated with it are also important.7 A sense of belonging to a facility where all health problems can be managed is reassuring and promotes adherence to the advice given.5 Medical homes foster a culture of partnership and expectation and those enrolled accept the obligation to deal with problems that might produce illness or compromise its management. Likewise, the medical team is responsible for helping their patients to avoid or manage health problems.8,9

The staff of a well resourced medical home might include doctors, nutritionists, a social worker, various nurse specialists, physiotherapists, occupational therapists and a dental hygienist. For example, in a new suburb with young families, the medical home might have paediatric nurse specialists and pregnancy management experts, but elsewhere with an older demographic, nurses with geriatric and palliative care expertise might be essential. The exact nature of a given team is determined by the needs of the patients enrolled in the practice. In other countries, the most successful medical homes use electronic health records and offer members electronic connectivity with their team. The Kaiser Permanente group in the United States has turned two million face-to-face consultations with a general practitioner into email-based consultations over the past 10 years to the satisfaction of all parties.10

Because of the continuity of care, which involves appropriately scheduled visits, the team is aware of patients whose health is fragile and who need care in their homes or other community setting. Outreach to such patients can markedly reduce deteriorations that might require hospital admission.5 An effective community intervention in the 3 weeks before patients require hospital care may reduce the number of preventable admissions, which are estimated to be about 600 000 per year in Australia.11 Electronic connectivity — using platforms such as email, Facebook or FaceTime with patients, their carers and local hospitals — is imperative for this model.12

Specialists may wish to affiliate with medical homes, but if international trends are followed, more specialists will visit or practice near medical homes creating what has been referred to as the “patient-centered medical neighbourhood”.13

The model focuses on mutual respect for the skills of different health professionals and a commitment to the central role of the patient with an emphasis on prevention.

After 2009, many countries (eg, the United Kingdom, US and New Zealand) using well resourced medical homes have reported reductions in hospital admissions of 20–24%.5,6

Introduction of the medical home model to Australia

The Australian government has recently announced plans to establish a trial of health care homes with the aim of “[providing] continuity of care, coordinated services and a team based approach according to the needs and wishes of the patient”.14 The trial of this model, for which the government is providing $21 million, is due to start in July 2017, and finish 2 years later. Few details have been provided, but the concept is far from the fully resourced medical homes, whose effectiveness is supported by a strong evidence base. The government’s model relies heavily on some services, such as allied health, being provided outside of the medical home by the 31 Primary Health Networks.

Clinical and consumer champions of the initiative, who have embraced the concept, have convinced others to try the model. Government support, but not imposition, is critical and was a feature of the successful development of integrated primary care in New Zealand.15 Persuasion not regulations are needed and the old will for some time co-exist with the new.

In Australia, the introduction of better integrated primary care delivered from well resourced medical homes as a taxpayer-funded service will require professional, community and political support. The Royal Australian College of General Practitioners,2 the Royal Australasian College of Physicians16 and the Australian Medical Association17 have endorsed the need for trials of the model in Australia. The opposition to the move from all Medicare payments being a fee-for-service has dissipated.17 The model is easily understood by consumers and enthusiastically embraced in many countries.12,18

Remuneration and structure

Remuneration for GPs will occur via a blended payment model, where the majority of income is derived from salaried or contractual arrangements, not fee-for-service payments. Since 2009 in New Zealand, 85% of the public have enrolled in a primary health care program and 85% of GPs are being remunerated via this model.19 Similar initiatives have occurred in the US since 2011, where in many areas, around 65% of GPs are being remunerated using a blended payment model.5,20

Looking at international trends and the history of provision of primary care by the private sector in Australia, we envisage that most medical homes will be independent, privately run organisations. Many of them may be established as companies limited by guarantee or as not-for-profit organisations.12 Consumer involvement will be enhanced by representation on the boards of such companies. Clinicians will be financially rewarded for keeping patients healthy. Through their efforts, the clinical team will build up a business that is valuable and their equity in the endeavour improves their overall financial wellbeing.12

Costing and funding

Pricing skills have been developed in Australia over the past decade to support activity-based funding for hospital care, where the hospital is funded for the casemix of patients it treats. Similar methodology will be needed as we develop new costing and payment systems for primary care services.

There is evidence that the medical home model of care can be adequately funded, with overall expenditure on health remaining in the range of 10–12% of the gross domestic product.21 Over time, the growth in the amount of funding required will be offset by the increased productivity of a healthier population.

A continuous effort to reduce health system-wide inefficiency will be equally important as we move to implement the new model of primary care. Ongoing work of agencies, such as the Agency for Clinical Innovation, to standardise optimal regimens for disease management must continue.22 Dissemination and uptake of these recommendations will reduce variations in clinical care and improve cost effectiveness. Savings will also come from reductions in rates of hospital admission and specialist visits.5,23

Experience from the implementation of this model, in Australia and internationally, will provide a constant stream of learnings that may lead to refinements of the outlined blueprint. However, there is an acceptance among countries in the Organisation for Economic Co-operation and Development that contemporary health systems need to emphasise and resource both prevention strategies and team management of chronic disease if health care is to be equitable and cost-effective.

[Correspondence] No health without peace: why SDG 16 is essential for health

We live in an increasingly globalised world in which almost 34 000 people a day are forced to flee their homes because of conflict and persecution.1 Refugees are increasingly moving into more traditionally stable countries, often risking their lives in the process, catalysing public health crises anew. As of 2015, more than 65 million people have been forcibly displaced worldwide; more than 20 million of them since 2011.2 The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), established in 1949, provides humanitarian assistance through education, health-care, and relief and social services, to some 5 million Palestine refugees alone in Lebanon, Jordan, Gaza, the West Bank, and Syria.

Bulk billing falls back, patient costs rise

The GP bulk billing rate has fallen back and patient out-of-pocket costs have jumped in what could be an early sign that the Federal Government’s Medicare rebate freeze is forcing general practices to increase patient charges to stay financially viable.

Repeated AMA warnings that medical practices were being driven by the rebate freeze to reduce or abandon bulk billing and hike patient charges have been leant weight by Health Department figures showing the bulk billing rate fell from 85.9 to 85.4 per cent in the September quarter while out-of-pocket costs surged 4.5 per cent to reach an average of $34.61.

While the AMA urged caution in reading too much into one quarter’s figures, the results could be the first confirmation of fears that Government policy is pushing up the cost of seeing a GP, including for vulnerable patients, such as those with chronic illness or on welfare.

“We know that the patient rebate is in many cases inadequate to maintain quality medical practice,” AMA President Dr Michael Gannon said.

In their search for ways to stay afloat, practices appear not only to be cutting back on bulk billing but also looking to charge non-bulk billed patients more.

Government figures show the average patient contribution increased at more than six times the pace of inflation in the September quarter, a heavy financial blow to households already stretched by near-stagnant wage growth, fuelling fears that patients will increasingly defer or forego seeing a doctor.

While decrying the “obsession” of both sides of politics in using the bulk billing rate as a measure of the quality of health care people receive, Dr Gannon said the Medicare figures nonetheless highlighted the importance of the Medicare rebate in funding primary health services, and the consequences when it failed to keep pace with the cost of providing care.

“The statistics show that Australians pay above-average out-of-pocket expenses, which is a sign that patient rebates are inadequate in funding our health system,” he said.

But Health Minister Sussan Ley claimed the latest Medicare data showed GP bulk billing rates remained at record high levels.

Seizing on figures showing the bulk billing rate in the September quarter was almost 1 percentage point higher than the same period last year (84.6 per cent), Ms Ley said the result was an affirmation of the Government’s policies.

“These ongoing increase in bulk billing rates are underpinned by our record investment in Medicare, which is increasing by $4 billion over the next four years,” the Minister said.

But Shadow Health Minister Catherine King said the quarterly result belied the Minister’s claims.

“This is the evidence Malcolm Turnbull didn’t want revealed – bulk billing is dropping and he knows it,” Ms King told reporters. “Australians are already seeing the impact of his six-year Medicare freeze every time they go to the doctor with more and more patients having to pay out of their own pocket.

“On the day before the election Malcolm Turnbull promised that no Australian would pay more to visit the doctor – this was a complete and utter lie.

“The Government needs to pull their head out of the sand and admit that their health policies are hurting Australians.”

AMA President Dr Michael Gannon has directly lobbied Prime Minister Malcolm Turnbull to immediately end the rebate freeze, warning that the increasing financial squeeze on medical practices was forcing many to cut bulk billing and increase patient charges in order to remain financially viable.

Medicare rebates have been frozen since 2014, and under current plans will not be indexed until at least 2020.

Ms Ley has talked down hopes that the policy could be reversed soon, arguing the Government cannot afford to recommence indexation until its finances improve.

The Government is due to release its Budget update next month, but the Parliamentary Budget Office has reported a further deterioration in the Government’s finances, projecting that the deficit will balloon to $105.1 billion by 2018-19 – an $8.9 billion blow out from the Budget.

The latest Medicare statistics show the bulk billing rate for the September quarter ranged from a high of 88.7 per cent in New South Wales to a low of 60.3 per cent in the Australian Capital Territory.

Latest news

[Series] The scale, scope, coverage, and capability of childbirth care

All women should have access to high quality maternity services—but what do we know about the health care available to and used by women? With a focus on low-income and middle-income countries, we present data that policy makers and planners can use to evaluate whether maternal health services are functioning to meet needs of women nationally, and potentially subnationally. We describe configurations of intrapartum care systems, and focus in particular on where, and with whom, deliveries take place.

UK’s ‘stunning own goal’ could feed doctor exodus

The British Government has been accused of a “stunning own goal” over its muddled plan to make the country self-sufficient in doctors by the middle of the next decade.

Just days before Prime Minister Theresa May told senior National Health Service officials there would not be any more money for public health services when the Government issues a financial update this month, Health Secretary Jeremy Hunt announced an extra 1500 home-grown doctors would be trained each year from 2018 in order to reduce the nation’s reliance on international medical graduates.

Under the plan, which the Government said would cost £100 million (A$160 million) in its first two years, doctors would be fined £220,000 (A$352,000) if they left the NHS before completing a minimum four years of service.

The goal is to make the country self-sufficient in doctors by 2025.

Mr Hunt outlined the plan as a response to concerns that a shortage of medical practitioners is contributing to overwork and poor morale among NHS doctors.

Ms May also portrayed it as a way to reduce the country’s reliance on practitioners from overseas to help fill workforce gaps – an issue with heightened implications given the UK’s decision to cut ties with the European Union.

But, coming against the backdrop of a bitter dispute over the Government’s attempts to impose new work contracts on junior doctors, the policy has been criticised by some as ham-fisted and ill-conceived.

Harrison Carter, co-Chair of the British Medical Association’s medical students committee, told The Lancet the initiative was poorly directed and failed to address the underlying problems afflicting the UK’s medical workforce.

“It’s a stunning own goal by the Secretary of State [for Health],” Mr Carter said. “[The Government] needs to deal with the underlying issues causing doctors to walk away from the NHS.”

A recent survey of 420 British doctors who have graduated in the past decade found that 42 per cent planned to practise overseas, because their experience of work was worse than they had expected. A further 16 per cent said they had “taken a break” from their medical career.

The results have underlined concerns that the bruising industrial battle over work contracts, which involved unprecedented strikes, has created significant ill-will and disillusionment among junior doctors, encouraging many to look elsewhere to develop their careers.

Dr John Zorbas, Chair of the AMA Council of Doctors in Training, told the Financial Times that there was strong interest among young UK doctors about working in Australia.

“When I speak to my overseas trained colleagues already working here, interest from UK doctors in training about working in Australia is high,” Dr Zorbas said. The AMA has written to the UK Government about the [NHS] dispute, which is no doubt impacting on the morale of doctor sin training in the UK. Unfortunately, it appears the Government’s agenda is more about an attack on working conditions than improving the quality of care for patients.”

Mr Carter said Mr Hunt’s plan to create extra training places and impose a four-year service requirement was no solution.

“This is not the way to address the crisis in morale in the profession,” he said. “What they will be faced with is doctors who are disillusioned, with low morale, and who will be bound to their job, not because of desire but because of an obligation.”

His concerns have been echoed by Royal College of Physicians Registrar, Andrew Goddard, who told The Lancet that although the extra training places was welcome, an extra 1500 graduates a year was not enough.

There is also dismay at the way the Government has sold its policy, particularly remarks by the Prime Minister regarding overseas trained doctors.

In an interview following the announcement, Ms May should doctors from overseas would stay “in the interim period until the further number of British doctors are able to be trained and come on board”.

While the PM later clarified her comments to say that overseas trained doctors did not have to leave, senior figures in the profession said the remarks were damaging.

“I think it is really dangerous to start thinking that all overseas doctors are about to go home,” Medical Schools Council Chief Executive Katie Petty-Saphon told The Lancet. “We really appreciate the work of overseas doctors…and the NHS would fall over without them. They are welcome here and they need to stay here.”

Mr Carter said the Prime Minister’s comment betrayed confused thinking within Government over the push to self-sufficiency in doctors.

He said if the goal was to train local doctors to take over roles currently filled by overseas trained practitioners as well as meeting the growing need for health care, the Government would need to train many more than just 1500 extra a year.

“There is no way that by 2025, with the 1500 who will come in [from] 2018, we will be anywhere near being self-sufficient,” Ms Petty-Saphon said.

Adrian Rollins

Mental health groups urged to boycott new plan

A prominent mental health advocate has blasted the Government’s draft Fifth National Mental Health Plan as “rubbish”, and called on mental health groups to boycott the consultation process.

The plan was released for consultation on 20 October, with Health Minister Sussan Ley describing it as “an important document” that was “focused on actions that will genuinely make a difference for consumers and carers”.

“The Fifth Plan contains seven priority areas, which have been identified for action in close collaboration with the mental health sector,” Ms Ley said in a statement.

But Professor John Mendoza, the former head of the Mental Health Council of Australia, said the plan would simply continue funding late-term intervention at the expense of prevention and early intervention.

Professor Mendoza called on colleagues at an international mental health conference in Brisbane that the consultation process should be boycotted.

“The plan does not reflect the Prime Minister’s commitment at the election ‘to leave no stone unturned when it comes to mental health’,” Professor Mendoza told The Australian, adding that the plan was “mealy-mouthed rubbish” designed by bureaucrats with no institutional knowledge.

“The plan does not take us one step further in relation to the Government’s announcements last November when it responded to the National Mental Health Commission report and it strongly endorsed the national commission’s recommendations.”

Professor Mendoza said that Prime Minister Malcolm Turnbull had used the words “we need to really embrace innovation, we have to focus on the mental wealth of the nation”.

“And he was stating that because it was clear to him that the economic drag on Australia now, through its focus on acute, late-intervention services rather than early intervention and prevention, means that we have hundreds of thousands of Australians who are unable to participate in work, who are unable to complete education, who are unable to sustain and maintain relationships, because they simply can’t get access to the care they need,” Professor Mendoza said.

“The Commission said this isn’t good enough, we need fundamental reform. And the Government said that was what it was going to do.

“Now, the Fifth Plan that’s been released for consultation does nothing of the sort.

“It pays no attention to the Government’s reform agenda, and it certainly doesn’t marry up with what either the Queensland and NSW Governments [are doing] – two different sides of politics, both of them have articulated clear plans.

“This national plan is completely devoid of any specific actions, any measures, any targets.”

The seven priority areas are:

Integrated regional planning and service delivery;
Coordinated treatment and support for people with severe and complex mental illness;
Suicide prevention;
Aboriginal and Torres Strait Islander mental health and suicide prevention;
Physical health of people living with mental health issues;
Stigma and discrimination reduction; and
Safety and quality in mental health care.

The Department of Health and Mental Health Australia will hold consultation meetings in all capital cities, as well as Townsville and Alice Springs, in November and December.

The final plan will be considered by the Australian Health Ministers’ Advisory Council and the COAG Health Ministers’ Council early next year.

Maria Hawthorne

Whooping cough booster faces axe

The Federal Government may axe the whooping cough vaccine booster for first year high school students as it pulls plans for an Australian Schools Vaccination Register.

An immunisation expert group has been asked to review the pertussis vaccine schedule, including the need for a booster currently being administered to children in secondary school.

The Government has announced that the Australian Technical Advisory Group on Immunisation (ATAGI) has been asked to “provide advice on the clinical place and effectiveness of the pertussis vaccine schedule, including the pertussis booster currently given in the first year of high school”.

Currently, it is recommended that infants receive a dose of the diphtheria-tetanus-acellular vaccine at two, four and six months of age, with further boosters at 18 months and four years. An additional booster is given between 12 and 17 years.

The review comes at a time when the number of whooping cough cases is in decline – about 16,000 cases have been notified so far this year, well down from the 22,500 infections reported in 2015.

But the decline has come not long after the country’s largest-ever recorded outbreak of the disease, between 2008 and 2012, including 38,732 notified cases in 2011 alone.

The National Centre for Immunisation Research and Surveillance said whooping cough was a “challenging” disease to control because immunity waned over time, and epidemics occurred every three to four years.

The Centre said declining immunity was a factor in the last major outbreak, during which 4408 people were hospitalised, including 1832 babies. Between 2006 and 2012, 11 died from pertussis, all but one of them infants less than six months of age.

The review of the pertussis vaccination schedule coincides with the decision not to proceed with the creation of the Australian Schools Vaccination Register.

The Health Department said it had discontinued the tender process for the creation of the Register following advice about the review of the pertussis booster vaccine for secondary school students and the end, in 2018, of the catch-up varicella vaccination program for adolescents.

The Register was announced in the 2015-16 Budget as part of the No Jab No Pay policy, and was portrayed as vital in helping to controlling infectious disease outbreaks by identifying areas where vaccination coverage was low.

But Health Minister Sussan Ley said it had now been “put on hold…pending further advice from independent medical experts on the vaccination needs of adolescents”.

The Health Department said it was possible that the Schools Register would only hold data on the human papilloma virus (HPV) if the pertussis booster for adolescents was axed and once the varicella catch-up vaccination program ends.

The Health Department said it was now looking at alternatives to the Schools Register, including the inclusion of such data in the whole-of-life Australian Immunisation Register which began operations on 30 September.

It is also in discussions with the Victorian Cytology Service about continuing the HPV Register in 2017.

Commonwealth Chief Medical Officer Professor Brendan Murphy was keen to assure that these changes would have “no impact on the health of adolescents because the full range of vaccination services are being delivered to the community, and will continue to do so”.

The move to axe the Register has coincided with the release of Government figures showing that almost 200,000 children have had their vaccinations brought up-to-date following the introduction of the No Jab No Pay reforms.

The figures, reported in the Sunday Herald Sun, show that since the reforms were introduced on 1 January, 86,562 families, including 102,993 children, have been denied childcare payments, and $38 million of Family Tax Benefit A benefits have been suspended. Parents of 8896 children are still not meeting vaccination requirements.

But 183,000 children have had their vaccinations brought up-to-date as a result of the program, under which parents face losing Family Tax Benefit A and childcare payments if they let their child’s immunity slip.

Adrian Rollins

Penny pinching threatens chronic care reform

The Federal Government’s landmark Health Care Homes reform is at risk of collapse because of a lack of funding, the AMA has warned.

Health Minister Sussan Ley has announced that $100 million will be provided to support the phase one trial of the reform, involving 65,000 patients and 200 medical practices in 10 regions across the country.

Under the Government’s plans, practices will receive monthly bundled payments worth an average $1795 a year to manage patients with chronic and complex health conditions. Payments will vary from $591 for chronically ill patients who can largely self-manage their condition to $1267 for those who need more intensive care and $1795 for those with the most complex health demands.

The allocations mean that patients on the lowest level of subsidy will be funded for just 16 visits to the doctor a year, rising to 48 visits a year for those deemed of highest need.

Controversially, such patients would only be eligible for five extra Medicare-subsidised visits to the doctor for health issues that lie outside their chronic illness – a major change from the current system under which patients have uncapped access to GP care.

A spokesperson for Ms Ley told Fairfax that five-visit cap was only an “indicative figure for modelling and planning purposes”, and said no patient would have their access to Medicare restricted or capped.

Ms Ley said Health Care Homes allowed for team-based, integrated care and would provide increased flexibility and coordination of services to tailor treatment to individual need.

But the details of the trial have reinforced suspicions that the Government is undertaking Health Care Homes primarily as a cost cutting exercise, and the AMA voiced concerns that if the reform was not adequately funded it could founder.

“The modelling is concerning and potentially leaves the whole program at risk of falling over because of being underfunded from the beginning,” AMA Vice President Dr Tony Bartone told News Corporation.

Dr Bartone, a GP, is the AMA’s representative on the Government’s Health Care Home Implementation Advisory Group, which last met on 30 September.

He said that, if appropriately funded, Health Care Homes could support GPs to keep patients healthier and out of hospital, but added the Government needed the goodwill of general practitioners if its trial was to succeed.

“That goodwill will evaporate significantly if there is not the appropriate funding,” he warned.

Earlier this year, AMA President Dr Michael Gannon warned that appropriate funding would be a “critical test” of the success or otherwise of the reform.

“BEACH data shows that GPs are managing more chronic disease. But they are under substantial financial pressure due to the Medicare freeze and a range of other funding cuts,” Dr Gannon said.

“GPs cannot afford to deliver enhanced care to patients with no extra support. If the funding model is not right, GPs will not engage with the trial and the model will struggle to succeed.”

Adrian Rollins

Australians shedding their hard drinking image

Drinks sales are forecast to decline as growing numbers of Australians cut back on their consumption or quit altogether, in a sign that higher excises and lock-out laws are helping to curb the nation’s drinking problem.

Industry analyst IBISWorld expects per capita alcohol consumption, which has already dropped to a 50-year low, will continue to decline until at least the middle of the next decade as people heed health messages and respond to higher prices, drink-driving laws and other measures by reducing their intake.

The analyst predicts that by 2024 consumption will drop to 8.54 litres per person, a fall of almost 20 per cent from the start of this decade.

“We’re seeing increasing health consciousness among the under 30s, while at the other end of the market people are also drinking less,” IBISWorld senior analyst Andrew Ledovshkik told The Australian Financial Review.

The analysis echoes the findings of an Australian Institute of Health and Welfare report showing that consumption is declining, with 22 per cent reporting they had abstained from drinking in 2013 (up from 17 per cent in 2004), and the proportion who have never had a full drink reaching 14 per cent.

Even rates of risky drinking are declining.

The AIHW reported an 11 per cent drop in the rate of Australians drinking at risky levels on a single occasion (from 2950 to 2640 per 10,000 people), and 13 per cent drop who indulge in risky drinking over a lifetime, from 2080 to 1820 per 10,000.

The declines have paralleled changes to the cost and availability of alcohol.

The excise on beer and spirits is indexed twice a year and for some beverages has reached $81.21 per litre of alcohol. Wine is treated differently and is subject to a so-called equalisation tax currently set at 29 per cent of its wholesale value. Public health advocates are critical of the arrangement and argue that alcohol should be taxed at a minimum unit price that applies regardless of the beverage.

Several State governments, most notably New South Wales and Queensland, have also acted to restrict outlet trading hours and impose lock-outs in response to alcohol-fuelled assaults and murders.

The Institute said the results suggested that strategies including increasing the price of alcohol, restricting trading hours and reducing the density of outlets “can have positive outcomes in reducing the overall consumption levels of alcohol”.

Aside from making alcohol more expensive and difficult to get, there are signs that younger people are less inclined to drink to the same extent as older generations.

In the United States, a survey of 67,000 youths and adults conducted by the Abuse and Mental Health Services Administration found that just 9.6 per cent of adolescents aged between 12 and 17 years reported drinking alcohol in 2015, down from 17.6 per cent in 2002.

The question is whether others drugs are being used as a substitute for alcohol.

In the US, there has been a slight drop in heroin use, but prescription drug use and abuse is high. It is estimated that about 19 million Americans aged 12 years or older misused prescription drugs, mainly painkillers, in the previous year.

In Australia, about 3.3 per cent of those 14 years or older have used analgesics for non-medical purposes in the previous 12 months, 10 per cent have used cannabis, 2.1 per cent have used cocaine and methamphetamine, 2.5 per cent have used ecstasy, 1.3 per cent have used hallucinogens and 0.1 per cent have used heroin.

But even with the decline in its consumption, alcohol remains a major health problem. It was the leading cause of disease burden for the under 45s in 2011, and alcohol use disorders accounted for 1.5 per cent of the total burden of disease that year.

Adrian Rollins