Government targets quality in proposed PIP overhaul

The AMA has expressed concern that a proposed major shake-up of the Practice Incentives Program is not being supported by increased investment in general practice.

The Health Department has unveiled plans to “refresh” the 18-year-old PIP system by slashing the number of incentive payment categories on offer, reducing the administrative burden on practices and intensifying the focus on quality.

Under the proposal, outlined in a discussion paper released by the Department, seven existing payments covering asthma, cervical screening, diabetes, aged care access, prescribing, Indigenous health and procedural GP incentives would be axed; four existing payments, covering rural loading, after hours services, teaching and e-health – would be maintained; and a new Quality Improvement Incentive payment would be introduced.

The AMA has welcomed the increased focus on quality, and is in consultation with the Department over the proposal to collapse the PIP payment categories.

But it voiced concern that the changes were not being supported by an increase in financial support for GPs, particularly given that many practices are being pushed to the financial brink by the Medicare rebate freeze and the prospect of cuts to pathology collection centre rents.

The Department has indicated that there will be no extra money injected in the PIP scheme.

It said the quality incentive payment would be used to “give general practices increased flexibility to improve their detection and management of a range of chronic conditions, and to focus on issues specific to their practice population”.

The push to overhaul the PIP system comes at the same time the Government is launching the initial stage of its Health Care Home model of care and undertaking a comprehensive review of the 5700 services listed on the MBS.

The Department said the initiatives together would “take the health system towards services that are aligned with contemporary practice”.

The case for changes to the PIP has been mounting in recent years, with a number of organisations including the Australian National Audit Office, the Organisation for Economic Co-operation and Development and the Grattan Institute all raising concerns that the system imposed an unduly heavy administrative burden on practices and was failing to keep up with evolving health needs and priorities.

The Department said the evidence showed that many existing incentives might be no longer appropriate, and that the more could be achieved by intensifying the focus on quality, including by making better use of data.

“Redesigning the PIP would enable it to move away from process-focused funding towards a simpler system that encourages quality improvement and innovation, and allows practices to see improvements in measures that are important to them,” it said.

Precisely how this could be achieved was up for consultation and debate, the Department added.

It suggested two options. One would be to merge all five PIP items (including the new Quality Improvement Incentive) into a single payment administered by the Department of Humans Services – essentially building on and adapting existing arrangements. Eligible practices would receive sign-on and quarterly payments, to be used to make quality improvements of their choosing.

Under the second option, the Department would no longer directly fund practices. Instead, practices would use PIP funds to engage third-party providers to support their quality improvement work.

Whatever the option chosen, practices would be required to regularly share data to map quality improvements, individually, locally and nationally.

The Government is inviting submissions on the proposed PIP overhaul. The deadline is 30 November.

The Department’s consultation paper can be downloaded here.

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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] The role of general practice in reducing mortality

We would like to thank Martin Roland for his Comment1 (July 16, p 217) about pay-for-performance primary care. The role of general practice and other primary care in reducing mortality has been centre-stage since Barbara Starfield2 reported in 2001 that each additional family physician was associated with a reduction of 34 deaths per 100 000. It is high time that this is clarified further.

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.

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GPs targeted in national plan to curb antibiotic resistance

GPs will be targeted over their antibiotic prescription practices as part of a national strategy to tackle the threat from rising antibiotic resistance.

Less than 10 days after researchers sounded the alarm over the arrival in Australia of a superbug capable of overcoming the last line of defence against salmonella infection, the Federal Government has detailed its plans to implement the National Antibiotic Resistance Strategy.

Health Minister Sussan Ley said the inaugural plan, covering the period 2015-19, had as one of its main targets reduced recourse to antibiotics by GPs.

“A particular focus will be Australia’s high use of antibiotics in general practice, which is 20 per cent above the OECD average,” Ms Ley said. “Bringing prescribing rates down is critical, as high antibiotic use is the number one driver of the increasing resistance to antimicrobials.”

Despite this focus Ms Ley, who launched the strategy in conjunction with Agriculture Minister and Deputy Prime Minister Barnaby Joyce, said the plan encompassed a broad “one health” approach which recognised the inextricable links between human, animal and ecosystem health.

“[This means] that combating resistance to antimicrobials requires action in all sectors where antimicrobials are used,” the Health Minister said.

The plan calls for, among other things, better support for doctors and vets in educating patients about the need for care in antibiotic use; the implementation of effective stewardship practices among health professionals; improved national surveillance of antibiotic use; better infection control measures; and intensified research efforts.

The plan has been developed amid mounting international alarm regarding the threat posed by antibiotic resistance. A recent British Government report warned the world was on track to a future in which even common infections and medical procedures could become potentially deadly because of the risk of infection.

The UK report estimated that antimicrobial resistance could kill 10 million a year by 2050, and cost the world a cumulative USD$100 trillion in reduced economic output without effective action to slow the rate of drug resistance.

The threat to Australia has escalated following the discovery by Murdoch University researchers of a strain of the Salmonella bug that is resistant to carbapenems, the drug used as the last line of defence against such infections.

The superbug was discovered in a pet cat admitted to Concord Veterinary Hospital in New South Wales with an upper respiratory tract infection that subsequently developed into a gut infection.

A sample of the infection sent to a team of researchers at the Concord Hospital identified a strain of Salmonella never before seen in the country. It was found to be carrying the highly resistant IMP-4 gene.

A further three animals at the veterinary clinics were also found to be infected with the superbug. The outbreak has been contained.

Dr Abraham said the identification and containment of the bacteria was “an example of Australia’s One Health capabilities, where animal and human health specialists work together to prevent the spread of infection”.

Adrian Rollins

[World Report] Frontline: Helping women deliver in South Sudan

Claire Reading is a midwife in Somerset, UK, who has worked in England’s National Health Service since 2007. On her second mission with Médecins Sans Frontières (MSF), she is serving as a midwife supervisor at a primary care health clinic in the remote South Sudanese town, Bentiu.

After-hours medical deputising services: patterns of use by older people

The known Older people are using emergency medical services at increasing rates. Little is known about their use of alternative care options, such as after-hours primary care and deputising services.

The new Residents of aged care facilities more frequently used medical deputising services than patients dwelling in the community; their increase in use over 2008–2012 was nearly double that of older people in the community.

The implications The increasing use of medical deputising services by older patients highlights the need to better integrate them with existing services, and for oversight to ensure their appropriate use.

Australian acute health care services handle an ever increasing number of emergency department (ED) presentations, especially by older patients.1 Similarly, the need for emergency ambulance transportation for people aged 85 years or more has risen dramatically.2 With an ageing population, the demand on ED services is expected to increase even further,3 but an estimated 40% of all ED presentations are potentially avoidable and could be handled safely by primary care services.4 Using emergency services for non-emergency conditions places an excessive burden on ED resources, diminishes the capacity of ED staff to respond effectively to serious, time-critical emergencies, and compromises patient safety.5,6

A range of alternative after-hours primary care service models could reduce avoidable demands on emergency services, including medical deputising services, telephone triage and advice lines, minor injuries units, general practitioner clinic cooperatives, and co-located GP clinics in hospitals.7–9 For their accreditation, operators of general practices are required to make appropriate arrangements for after-hours care of patients. However, accessibility to after-hours primary care services can be particularly challenging for older patients, who are more likely to need them because of comorbid conditions, increased medical needs, difficulties with transport, or a reluctance to leave their home alone at night.10 The delivery of more appropriate after-hours primary care for this age group through home visits by a GP is one practical option.

Several medical deputising services arrange after-hours home visits by GPs. Patients may be visited by a locum GP employed by the deputising service, or it may act as an answering service for the person’s regular GP if they are available to attend their patient.8 In Australia, the proportion of GPs working in practices using medical deputising services has increased significantly over the past decade, in contrast to the declining fraction who work in practices that provide after-hours care, either autonomously or in cooperation with other practices.11 The increased use of medical deputising services for after-hours care may be due to changes in policy that encourage GP support organisations (formerly Medicare Locals, now restructured as Primary Health Networks) to improve access to after-hours primary health care services by promoting medical deputising services9,12 and lifting the ban on medical deputising services directly advertising their services to the community, so that they need not rely on GP referrals alone.

Although the use of medical deputising services in Australia has increased, little has been published on how they are used for after-hours care by older patients, who both comprise a growing proportion of the population and contact emergency services with increasing frequency.2,3 We therefore examined how older people used a medical deputising service in Melbourne, and compared differences in patterns for people living in residential aged care facilities (RACFs) and private residences. In 2011, 94% of Australians aged 65 years or more lived in private dwellings and about 4% in RACFs, including nursing homes and accommodation for the retired or aged, but excluding self-contained units in retirement villages.13

Methods

This study was part of a larger, four-phase research program investigating strategies for reducing avoidable presentations by older people for emergency care treatment (REDIRECT).14

Data

We conducted a retrospective analysis of administrative data collected by the Melbourne Medical Deputising Service (MMDS). During 2008–2012, MMDS was one of the major medical deputising services in Victoria, serving greater metropolitan Melbourne and its surrounding areas, including Geelong (Box 1). Telephone requests for medical care were triaged by an MMDS operator as being appropriate for an after-hours GP visit, and then logged as a booking.

According to criteria set by the federal government, the after-hours period for health care was defined as follows:15

Weekdays: before 1 May 2010, outside 8 am–8 pm; from 1 May 2010, outside 8 am–6 pm;
Saturdays: before 1 May 2010, outside 8 am–1 pm; from 1 May 2010, outside 8 am–12 noon; and
Sundays and public holidays: all day.

GP home consultations (bulk-billed for holders of Department of Veterans’ Affairs [DVA] cards or Commonwealth Seniors Health Cards) were held during these after-hours periods, but MMDS call centres were open to receive calls and to log bookings 2 hours prior to the start of weekday and Saturday MMDS consultation times, and all day on Sundays and public holidays.

All bookings logged for patients aged 70 years or more during 1 January 2008 – 31 December 2012 were included in our analysis. Routinely collected patient information for each telephone booking included demographic data, accommodation type (RACF or non-RACF), and the patient’s usual GP. Caller information was also recorded.

When calculating telephone bookings rates, we used Australian Bureau of Statistics (ABS) annual population data to estimate the number of people aged 70 years or more residing in the MMDS coverage area,16 which we defined as encompassing the following ABS geographical units: Greater Melbourne (Greater Capital City Statistical Area [GCCSA] geographical unit code 2GMEL), Geelong (Statistical Area Level 3 [SA3] geographical unit code 20302), and Portarlington, Clifton Springs, Queenscliff and Ocean Grove-Barwon Heads (SA2 units) (Box 1).

To assess the influence of socio-economic status, patients were allocated to Index of Relative Socio-Economic Disadvantage (IRSD) deciles (ranked within Victoria)17 according to the postcode of their usual place of residence. Socio-economic status deciles were compiled into quintiles, the first quintile corresponding to the most disadvantaged 20% of the population, and the fifth quintile to the 20% least disadvantaged.

Statistical analyses

The primary outcome was a telephone booking for an after-hours GP visit. The primary exposure variable of interest was the patient’s accommodation type. Data were summarised as descriptive statistics. The demographic characteristics of RACF and non-RACF patients and their utilisation of the MMDS service were compared in cross-tabulations. For categorical data, frequencies and proportions were calculated and associations assessed in χ² tests. For continuous data, means and standard deviations were calculated, and differences between groups of normally distributed data compared in t tests. All analyses were performed in Stata 13.1 (StataCorp).

Ethics approval

Approval for this study was obtained from the Monash University Human Research Ethics Committee (reference, CF13/3315–2013001738).

Results

Of the 357 112 bookings logged by MMDS for people aged 70 years or over, 290 264 (81.3%) were from RACFs (Box 2). The mean age of RACF patients was higher than for non-RACF patients, although the range (70–99 years) was similar for both groups. More women than men, and more people in the least disadvantaged IRSD quintile than in any other single quintile used the MMDS, irrespective of accommodation type. For RACF patients, the caller was typically a member of staff or the ambulance service; for non-RACF patients, callers included the person themselves or a family member, neighbours, or a district nurse or ambulance service staff member.

Most MMDS bookings resulted in a locum GP visiting the patient (RACF, 91%; non-RACF, 82%). An urgent transfer to hospital was organised for 6% of non-RACF patients, compared with 3% of RACF patients. Conversely, Ambulance Victoria, which triages non-emergency patients to GP services, referred 5% of non-RACF patients and 0.1% of RACF patients to the MMDS.

A small proportion of bookings were either cancelled or not acted upon (RACF, 8%; non-RACF, 16%). Reasons for cancellations included “no longer required: feeling better”, “unable to wait for a locum”, “called an ambulance”, “cancelled by district nurse”, “going to sleep”, “didn’t want to see a locum, only their usual GP”, and “no answer at door or on phone”.

MMDS booking rates

The number of MMDS bookings for RACF patients increased from 45 828 in 2008 to 69 901 in 2012; this 53% increase was significantly greater than the 34% increase for non-RACF patients (P < 0.001; Box 3). The booking rate for RACF patients increased during this period from 121 to 168 per 1000 people aged 70 years or more; the booking rate for non-RACF patients increased from 33 to 40 per 1000 people aged 70 years or more, but the trend was less consistent (Box 4). There was a relative increase of 39% in the rate of MMDS bookings for RACF residents between 2008 and 2012, and of 21% for non-RACF patients.

Peak use

MMDS bookings for an after-hours GP visit were most frequent on Saturdays and Sundays (Box 5). The peak booked consultation times were 6 pm on weekdays and 11 am on Saturdays and Sundays (Box 6). After-hours GP bookings were lowest during 1 am–5 am.

Discussion

Our study is the first to examine the use of an after-hours medical deputising service in Melbourne by older people. Most MMDS bookings were for people living in RACFs, with a steady increase in the frequency of bookings between 2008 and 2012. The booking rate for people not living in RACFs began to increase from 2010, coinciding with health reforms that included Medicare Locals facilitating regional after-hours access to primary care. Most MMDS bookings resulted in a locum GP visit, and only a small proportion of visits required an urgent transfer to hospital. Older women and individuals living in higher areas of higher socio-economic status were more likely to avail themselves of MMDS services.

The higher booking rate for patients in RACFs than for those in private dwellings (168 v 40 per 1000 people aged 70 years or more in 2012) probably reflects their greater frailty and poorer health,18,19 but may also reflect the lower number of GPs providing care to people in RACFs.20 Conversely, lack of knowledge about alternative after-hour primary care services among people not living in RACFs may have contributed to their lower booking rates.9,21 Cost is unlikely to be a factor for this group (including those living in areas of lower socio-economic status), as home visits to those with Seniors Health Cards or DVA cards were bulk-billed. The large increases in the relative booking rate for both RACF and non-RACF residents (40% and 20% respectively) indicate that the deputising service is responding to a growing and appropriate need, as only a small proportion of bookings resulted in an urgent transfer to hospital.

Six per cent of bookings for people not living in RACFs resulted in an urgent transfer to hospital; conversely, 5% of bookings outside RACFs were referrals by Ambulance Victoria (ie, non-emergencies). These disparate findings are understandable, as most callers who contacted the MMDS did not have medical training and could not accurately assess the seriousness of the patient’s condition. This interpretation is corroborated by the correspondingly smaller proportions of bookings for people in RACFs that either resulted in an urgent hospital transfer (3%) or were referrals by Ambulance Victoria (< 1%); these bookings were typically made by experienced RACF staff (eg, registered nurses). Alternatively, less experienced RACF staff on duty after hours may contact the MMDS for less serious problems, which would account both for the steeper increase in booking numbers for RACF residents and the lower proportion requiring urgent hospital transfer.

Two-thirds of bookings for people living in RACFs were for women, consistent with the sex ratio of older persons living in non-private dwellings in Australia (69% are women).13 In contrast, 64% of bookings for people living outside RACFs were also for women, slightly higher than the proportion of older women living in the community (about 56%). Difficulties with transport, living alone, personal safety fears, and a reluctance to burden family and friends may partly account for this difference.10,13,21 We also report greater use of the MMDS by people living in areas of higher socio-economic status, which suggests a need to raise awareness of the service among people living in less advantaged areas. This conclusion is supported by an earlier study which reported that people who seek care from an ED could not identify “alternative settings [for seeing] a doctor”.22 It is also consistent with the recommendation by a recent federal review of after-hours care that a pathway for consumers to high quality after-hours advice and support be developed.23 GPs also play a key role in advising patients on the most appropriate after-hours services for their specific needs, which is particularly important for frail and older people living in the general community.

Medical deputising services that arrange home visits by locum GPs overcome some of the barriers to seeking after-hours medical care by older patients, such as transport problems, reluctance to go out at night, and scepticism about telephone advice.10,21 Using these services may also reduce the negative effects of unnecessary ED presentations. The hectic environment of the ED can cause diagnoses and age-related syndromes to be missed in older patients with complex care needs.24 However, despite the overall satisfaction of older patients with medical deputising services,25 barriers to their use still exist, including lack of information about the service, reluctance to see an unfamiliar doctor not acquainted with their medical history, difficulty in obtaining medication after the consultation, and long waiting times.10,25,26

Because of the limited availability of GPs on weekends, older people tended to use the MMDS more frequently on Saturdays and Sundays. Further, peak use of the service was around the beginning of the after-hours period on weekdays and Saturdays. These data suggest that many older people are waiting for the service to open, or they may phone a GP clinic at about closing time and are then referred to a medical deputising service. Our analysis also found that MMDS bookings were lowest late at night (1 am–5 am). This may be because older people fear “being a nuisance”, deterring them from calling during these hours, or that they may prefer to wait to see a familiar doctor.10,20,21 Further qualitative research may provide further insight into the reasons underlying the pattern of use of the MMDS, as would comparing it with that of telephone information services, such as Nurse-On-Call.

As the use of medical deputising services increases, communication between the service and the patients’ usual GPs becomes more important in maintaining the continuity of their care, and particularly for ensuring the efficient handover of clinical information. Indeed, the recent federal review of after-hours care23 recommended that the accreditation of medical deputising services include a requirement for deputising services, and that those who provide after-hours care outside the practice should supply clinical summaries to the patient’s regular practice within 24 hours. Other services, including the nationally shared health record (My Health Record), will also assume greater importance.

Limitations

No distinction was made in our study between RACFs that provided high and low level nursing care, a distinction that applied prior to July 2014. Residents in these two RACF classes are likely to have had different medical needs. Additionally, we did not have any information about the health status of people not living in RACFs; some people, such as those with poorly managed chronic illnesses, may be more likely to require after-hours care. Further, utilisation of MMDS was assessed according to the number of bookings, but this does not distinguish between first-time users and repeat users. Comparing our data with data for telephone information services (eg, Nurse-On-Call) and the ambulance service (which can treat patients on site without transporting them to hospital) would also allow a more complete picture.

As this study is descriptive, it is difficult to impute reasons for some findings. Investigation of the factors associated with increased use of after-hours medical deputising services at critical time points would assist in meeting demand more effectively and improve service delivery. Longitudinal studies that track long term trends could assess the effect of after-hours medical deputising services on the demand for ED services.

Conclusion

Most MMDS bookings led to a locum GP visit, and most bookings were for general practice-type services and did not require a hospital referral. For patients not residing in RACFs, home-visit medical deputising services may be a viable alternative to seeking care from emergency services, as many older people have problems with transport. In 2015, new funding arrangements for providing after-hours services were introduced;27 Primary Health Networks will be charged with supporting locally tailored after-hours services by general practices and a new after-hours GP advice and support line. Nevertheless, medical deputising services remain a critical component of the after-hours landscape in Australia, supplementing the declining numbers of general practices that provide after-hours care. The increasing use of medical deputising services that we have identified will continue to complement telephone helplines and practices that provide their own after-hours care. Policy makers and health practitioners need to ensure that care is integrated and that inappropriate use of these services is not encouraged.

Box 1 –
Areas served by the Melbourne Medical Deputising Service, 2008–2012

Box 2 –
Socio-demographic and other characteristics for 357 112 telephone bookings with the Melbourne Medical Deputising Service for after-hours general practice care for persons aged 70 years or more, by place of residence type, 2008–2012

Characteristic	Place of residence type		P*
Characteristic	Residential aged care facility	Other	P*

Number of bookings	290 264	66 848
Sex of patient			< 0.001
Men	93 730 (32.8%)	23 696 (36.2%)
Women	191 708 (67.2%)	41 737 (63.8%)
Missing data^†	4826	1415
Mean age of patient (SD), years
Men	84.1 (6.5)	81.0 (6.2)	< 0.001
Women	86.1 (6.3)	81.1 (6.7)	< 0.001
Call was from Ambulance Victoria^‡			< 0.001
Yes	324 (0.1%)	2704 (5.4%)
No	220 039 (99.9%)	47 587 (94.6%)
Missing data^†	69 901	16 557
Socio-economic status (quintiles)^§			< 0.001
1 (most disadvantaged)	50 312 (17.6%)	11 428 (17.9%)
2	36 322 (12.7%)	6022 (9.4%)
3	51 112 (17.9%)	13 516 (21.1%)
4	66 974 (23.4%)	13 709 (21.5%)
5 (least disadvantaged)	81 114 (28.4%)	19 216 (30.1%)
Missing data^†	4430	2957
Patient’s GP clinic was an MMDS client with arrangements for an MMDS locum GP to provide after-hours care			< 0.001
Yes	239 955 (85.2%)	47 762 (76.7%)
No	41 632 (14.8%)	14 510 (23.3%)
Missing data^†	8677	4576
Outcome of booking			< 0.001
Patient attended by MMDS locum GP	263 706 (90.8%)	55 096 (82.4%)
Patient’s usual GP contacted	2621 (0.9%)	1088 (1.6%)
Request for locum GP cancelled	23 937 (8.3%)	10 664 (16.0%)
Urgent transfer of patient to hospital organised by MMDS locum GP^¶			< 0.001
Yes	8635 (3.3%)	3488 (6.3%)
No	255 071 (96.7%)	51 608 (93.7%)
Missing data^†	26 558	11 752

MMDS = Melbourne Medical Deputising Service. SD = standard deviation. * χ² tests for categorical variables; t tests for continuous variables. † Missing data were omitted from the denominator for percentages and from other calculations. ‡ Data for 2008–2011 only; data for 2012 were not available and comprise the missing data for this attribute. § Socio-economic status groups were generated using the Australian Bureau of Statistics’ SEIFA 2011 Index of Relative Socio-Economic Disadvantage (ranked within Victoria) and the postcode for the usual place of residence of the patient. For individuals living in a residential aged care facility, the postcode of the facility determined the socio-economic status group. ¶ Bookings where the patient was attended by an MMDS locum GP (318 802 people).

Box 3 –
Numbers of telephone bookings with the Melbourne Medical Deputising Service for after-hours general practice care for people aged 70 years or more, by type of residence, 2008–2012

Box 4 –
Population rate of telephone bookings with the Melbourne Medical Deputising Service for after-hours general practice care for people aged 70 years or more, by type of residence, 2008–2012

Box 5 –
Telephone bookings with the Melbourne Medical Deputising Service for after-hours general practice care for people aged 70 years or more, 2008–2012, by day of week and type of residence

Box 6 –
Telephone bookings with the Melbourne Medical Deputising Service for an after-hours general practitioner for people aged 70 years or more, 2008–2012, by day of week* and time of day

* The line for Monday–Friday bookings depicts the mean daily numbers of bookings on weekdays.

After-hours medical deputising services for older people

Older people need GPs who know them well

Medical deputising services are invaluable, responding to large numbers of after-hours calls, particularly for older people at home and in residential aged care (RAC). Without these services, emergency departments and ambulance services would be much busier than they are now. The article in this issue of the MJA by Joe and colleagues1 reviews 357 112 bookings logged by one such service, the Melbourne Medical Deputising Service (MMDS), over a 5-year period (2008–2012).

The proportion of general practitioners using deputising services increased from 38% in 2005–06 to 48% in 2014–15.2 The data presented by Joe et al show a concomitant increase in the number of home and nursing home visits by the MMDS for those over 70 years of age, with the booking rate rising over the 5-year period from 33 to 40 per 1000 people over 70 years of age for home visits, and from 121 to 168 per 1000 people for RAC visits.

The reasons for this increase are undoubtedly complex, and require further examination. They include the increase in the size of the population of older people, and government initiatives that encourage GPs to provide after-hours services, either directly or through deputising services. The annual collection of data on 100 000 GP consultations in Australia known as BEACH has revealed a GP workforce that is “more feminised, older … and worked fewer hours per week”.3 Other factors might include the dangers of after-hours visiting, stretched GP workforces, and a trend among GPs toward a better work–life balance.

Deputising services differ from ordinary general practice. There is no requirement for their doctors to have a college fellowship, and only about half of the doctors in the MMDS do so.4 There is little continuity of care. Older people have high rates of dementia and may not be able to fully communicate their history. It takes time to trawl through medical notes in RAC facilities. This potentially reduces the quality of service compared with attendance by the patient’s own GP, who knows them and their medical history well. On the other hand, the deputising service keeps track of their locum service doctors, and should know whether something has gone amiss.

The article by Joe et al notes that over 80% of calls were from or on behalf of patients in RAC. These patients represent less than 5% of the older population, and they present with levels of complexity and disability that have qualified them for entry to RAC on the basis of the ACAT (Aged Care Assessment Team) criteria. The authors of the study ask why there are so few community call-outs, but it might also be interesting to consider why there are so many RAC call-outs.

Only 48% of the BEACH GP sample in 2014–15 had visited an RAC facility in the previous month.3 Barriers to GP visits include the poor level of GP remuneration, increased time seeing the patients,5 difficulty in finding staff (or indeed the patient), and staff with training below the levels of registered or enrolled nurse who are unable to hand over the patient history in a manner that makes medical sense.6 Handover comments such as “Mrs Smith is a bit behavioural today” are very difficult to interpret clinically.

Nurses with the ability to attend to complex needs are currently few in number in RAC, particularly at night. Nurses with lower levels of training may follow protocols that require at least a phone call to a medical practitioner if certain parameters are exceeded (eg, blood pressure). This call is even more likely in some areas, where hospitals require a medical practitioner review before receiving an ambulance patient from RAC.

RAC providers argue that changes in the Aged Care Funding Instrument, which funds RAC, will result in a decrease of 11% in income, with over 50% of survey respondents stating they would be likely to reduce the number of nursing staff.7 The New South Wales Nurses and Midwives’ Association has called for an approach that also takes the patient’s needs into account:8

We should be looking to establish a needs-based system to determine staffing ratios, consistent with those found in public hospitals to ensure our health care system is equitable, and does not discriminate on the basis of age.

When a patient’s usual GP is unavailable, the deputising service may be called, resulting in the large number of visits found by Joe and her colleagues. The service doctors are not equipped to care for these complex elderly patients in an optimal manner; they do not necessarily have a postgraduate qualification, they do not know the patient, and they are not supported by staff who are well trained and familiar with the medical conditions of each patient. We need to examine the reasons for calls to medical deputising services, and whether they are associated with excess morbidity and mortality. It is a problem that might be partly ameliorated by systems such as Hospital in the Home.9 Urgent change is needed if we believe that our elders should receive at least the same quality of medical care as the rest of our community.

Health care homes: lessons from the Diabetes Care Project

Better care coordination, e-health tools and funding systems are essential for chronic disease management

One of the biggest health care challenges in Australia is ensuring that people with chronic diseases receive the care they need in a high quality and sustainable way. Today, one-third of the population — about 7 million people — have one or more chronic conditions, accounting for 85% of the total burden of disease, 90% of all deaths, 40% of general practitioner visits and 60% of disease-allocated health expenditure.1,2 As the National Health and Hospital Reform Commission noted in 2009, these patients often have great difficulty accessing appropriate care and “end up literally ricocheting between multiple specialists and hospitals, not getting access to community support services, and having endless diagnostic tests as each health professional works on a particular ‘body part,’ rather than treating the whole person”.3

In response to this challenge, and drawing on local and international experience,4–6 the commission recommended the concept of a health care home. The proposal was that people with chronic and complex health problems who chose to enrol with a single primary health care service as their health care home would be supported through a package of funding to strengthen continuity and coordinated, multidisciplinary care and health outcomes.3 The Diabetes Care Project (DCP) was a pilot of the health care home concept, conducted and evaluated from 2011 to 2014.7,8

In 2015, the Australian Government established the Primary Health Care Advisory Group (PHCAG) to re-examine this problem, and it recently announced that, from 1 July 2017, it would begin implementing a trial of health care homes in seven primary health network regions across the country.9,10 The health care home concept, as defined by PHCAG, aims to “provide holistic support and coordinated care for patients [and] support enhanced team based care … [while being] underpinned by shared information … [and] supported by new payment models”.9 Under the proposed model, eligible people with chronic diseases will be able to enrol with a GP practice or Aboriginal medical service, which will “co-ordinate all of the medical, allied health and out-of-hospital services required as part of a patient’s tailored care plan”.10 This will involve significant changes for both Medicare and the wider health care system. Moreover, funding to support people enrolled in health care homes will be bundled together into regular quarterly payments, signalling a move away from the current fee-for-service payment system for this population (except where a health problem does not relate to their chronic disease).

There have been various definitions of medical homes and health care homes described in the literature.11–14 The concept of the health care home proposed by the government is similar to the approach tested in the DCP, and it is timely to reflect on how lessons learned during that trial could inform current efforts to introduce a health care home model in Australia.7,8

The DCP was one of the largest randomised controlled trials of coordinated care for people with a chronic disease ever conducted. It involved 184 general practices and 7781 people with diabetes in South Australia, Victoria and Queensland from 2011 to 2014. Practices were randomised into a control group or one of two intervention groups. Group 1 received a new information technology system and regular updates on their performance, and group 2 received the same interventions as group 1 plus a new funding model similar to that being proposed by PHCAG for the new health care homes. After 18 months, participants in group 2 showed an improvement in the mean glycated haemoglobin (HbA_1c) level (the primary endpoint of the trial), while group 1 showed no benefits (Box).

How can these findings help us design and implement an effective health care home model for Australia?

First, the DCP highlighted that modifying current funding mechanisms is important if we are to create a health care system more suited to the needs of people with chronic and complex conditions. Better information systems and quality improvement processes alone were not sufficient to improve health outcomes in the trial. However, combining these changes with a new funding model that made it easier for providers to coordinate a patient’s care and that rewarded quality care made a significant difference. Although designing and implementing changes to funding systems is never easy (the status quo will always have a strong pull), this finding demonstrates that such changes can have a considerable impact on health outcomes for people with chronic diseases.

Second, the results from the DCP showed the challenge of implementing e-health tools and better information systems without sufficient focus on support to encourage their adoption. One of the most surprising findings from the DCP was that group 1 did not show any improvement in health outcomes. A closer look at the data suggests that this may, in part, reflect this group’s limited use of cdmNet — an online service that allows clinicians to access a shared electronic health record, automatically send referrals, generate pre-populated electronic care plans and display aggregated information about the health of their enrolled patients. In group 2, GPs used cdmNet twice as often, practice nurses used it three times as often, and allied health providers used it six times as often as their counterparts in group 1. Care facilitators in group 2 also relied heavily on cdmNet to prioritise tasks and identify the problems they could help with. Both intervention groups received the same training and technical support, but it is likely that cdmNet was used more in group 2 because the tool automated payments to practices and allied health providers (which made it much easier for them to get paid) and care facilitators reinforced its use in practices. As these results suggest, it is not sufficient to simply give people new health tools. Instead, these tools must be incorporated into the day-to-day model of care and people must be provided with compelling reasons for using them to have a meaningful impact on care delivery and health outcomes.

Last, the data gathered during the DCP highlight the importance of coordination between primary and secondary care. In the year before the trial, hospital costs accounted for almost half of total health care expenditure in the enrolled population.8 These costs were unevenly distributed, with 5% of participants accounting for about 50% of hospital costs, and 20% of participants accounting for over 80% of hospital costs. Despite this, people who were hospitalised more frequently did not receive a significantly greater allocation of chronic disease management and allied health funding than people in better health. In future programs, improved information sharing between primary and secondary care may help identify those most at risk of repeated hospitalisations and allow better targeting of resources to keep people well and reduce avoidable hospitalisations.

Shifting our health system towards a health care home model is a challenging task, and it is unlikely that initial attempts will be perfect. For this reason, it is important that implementation is accompanied by thorough and ongoing evaluations of the impact of this model on health outcomes, patient experience and value for money. The resulting data can then be used to inform refinements where necessary. In the longer term, the findings can be used to answer broader questions about the health care home model, such as: which people benefit most from the program? what is the clinician experience and how is clinical practice impacted? what is the ideal mix of fee-for-service, population-based funding and payment for outcomes? how do providers manage switching between the health care home model for some people and normal fee-for-service visits for others? and is the health care home model reducing hospital costs in the long term?

The government has indicated that a review of the health care home model will be considered in 2018 to determine whether it will be implemented in other parts of the country.15 Establishing the evaluation framework from the outset will strengthen the implementation and the value of the results, paving the way towards better-coordinated and more appropriate care for those with the greatest health needs.

Box –
Diabetes Care Project interventions and results8

Group

Interventions

Results

Group 1

cdmNet: an online care planning and shared health record tool for clinicians and patients.Regular reporting to practices on their clinical performance compared with peers.

No change in HbA_1c level (the primary endpoint).

Group 2

cdmNet: an online care planning and shared health record tool for clinicians and patients.Regular reporting to practices on their clinical performance compared with peers.Flexible payments of $130–$350 to practices, and $140–$666 for allied health care per year (which replaced funding for GP management plans and team care arrangements).Incentive payments of up to $150 per patient per year tied to quality of care, improvements in HbA_1c and patient experience.Funding for a salaried care facilitator, shared between several practices.

Improvement in HbA_1c level of 0.2 percentage points across the whole population (the primary endpoint).Larger improvements for people with starting HbA_1c above target range (eg, 0.6 percentage point improvement for people with HbA_1c above 9%).Statistically significant improvements in blood pressure, blood lipids, waist circumference, depression, diabetes-related stress, care plan take-up, completion of recommended annual cycles of care and allied health visits.

A population-based analysis of incentive payments to primary care physicians for the care of patients with complex disease [Research]

Background:

In 2007, the province of British Columbia implemented incentive payments to primary care physicians for the provision of comprehensive, continuous, guideline-informed care for patients with 2 or more chronic conditions. We examined the impact of this program on primary care access and continuity, rates of hospital admission and costs.

Methods:

We analyzed all BC patients who qualified for the incentive based on their diagnostic profile. We tracked primary care contacts and continuity, hospital admissions (total, via the emergency department and for targeted conditions), and cost of physician services, hospital care and pharmaceuticals, for 24 months before and 24 months after the intervention.

Results:

Of 155 754 eligible patients, 63.7% had at least 1 incentive payment billed. Incentive payments had no impact on primary care contacts (change in contacts per patient per month: 0.016, 95% confidence interval [CI] –0.047 to 0.078) or continuity of care (mean monthly change: 0.012, 95% CI –0.001 to 0.024) and were associated with increased total rates of hospital admission (change in hospital admissions per 1000 patients per month: 1.46, 95% CI 0.04 to 2.89), relative to preintervention trends. Annual costs per patient did not decline (mean change: $455.81, 95% CI –$2.44 to $914.08).

Interpretation:

British Columbia’s $240-million investment in this program improved compensation for physicians doing the important work of caring for complex patients, but did not appear to improve primary care access or continuity, or constrain resource use elsewhere in the health care system. Policymakers should consider other strategies to improve care for this patient population.