[Perspectives] Paying for performance: money, motivation, and uncertainty

Mr Watson, a new patient in my practice, sat on the examination table, clutching his hands. He studied the floor without speaking, rubbing his knuckles for a while before finally looking up. “So, are you advising against the PSA test because of the cost?”, he said. It was when I had finished his physical examination that Mr Watson had asked if I would do a prostate-specific antigen (PSA) test, something his previous primary care physician had done as yearly screening. I told him that, on the basis of his age, risk profile, absence of symptoms, and the risks versus benefits of testing, I did not think it was necessary.

Managing legal and medical complexities in caring for people with drug and alcohol problems: a call for change

How can we respond more effectively?

The current “ice (crystal methamphetamine) epidemic” has thrown into relief long-standing dilemmas for front-line practitioners dealing with the burden of care associated with drug and alcohol misuse in the face of legal complexity and insufficient support from the health system and other government agencies. Despite increasing investment in border protection and law enforcement, the Australian Crime Commission has been reporting growth in the importation, manufacture and supply of crystalline methamphetamine of increasing purity, leading to the establishment of the National Ice Taskforce.1 Concurrently, medical and public health bodies (including the Australian Medical Association, Public Health Association of Australia, and South Australian Network of Drug and Alcohol Services) are reporting under-resourcing of measures to reduce drug demand and to provide early intervention, treatment and rehabilitation in the community.2 The issues for clinicians are not new, and the views of the medical profession need to be strongly heard, so as to achieve rational, health-based policies in response to the ice epidemic and other drug problems, and to manage the problems associated with drug and alcohol misuse, particularly mental health issues.

Historically, in the first half of the 20th century, the predominant concern in Australia was with alcohol and alcoholism; then, the 1960s and 1970s saw an increase in public awareness of illicit drug problems. In 1985, then Prime Minister Hawke called a drug summit which instigated what is now known as the National Drug Strategy. The strategy addressed misuse of legal and illegal drugs, and upheld the principle of harm minimisation, subsequently seen in Australia’s response to the HIV/AIDS and hepatitis C “epidemics”.

However, legal and clinical responses have had different goals: while the legal system has aimed to restrict access to drugs and alcohol to prevent misuse and deter criminal behaviours, clinicians have aimed to prevent and manage the effects of drug misuse and associated secondary physical and mental health issues (including suicide risk and blood-borne virus transmission). As a result, law and medicine have often been in conflict in the sphere of drug policy.

The bottom line is that in the domain of clinical practice, associated legal complexities — especially when those affected are, or could be, “criminalised” — can complicate the implementation of effective management. In such circumstances, medical practitioners must try to negotiate complex interfaces between treatment, legislation, criminal justice and social disadvantage. It is among the socially marginalised — such as the homeless, prisoners and people with mental health disorders — that these interfaces are most notable.

In 1998, a comprehensive mental health survey of homeless people in Sydney night shelters found that while 36% had a drug misuse disorder, 75% had one or more mental health disorders and one in two had a physical health problem.3 Mortality was three to four times higher than that for the general population.4 In 2012, while 70% of surveyed Australian prisoners had used illicit drugs in the past year and 54% were drinking alcohol heavily before offending, 46% had received a mental health diagnosis in the previous 12 months and 21% were taking a prescribed psychotropic medication.5 Indigenous and female inmates were most likely to be affected by such health problems.5 The prison population also had high rates of blood-borne virus exposure.6

In 2013, the National Mental Health Commission reported that almost 340 000 Australians were both experiencing mental illness and misusing drugs, and up to 70% of patients who presented for a mental health or substance use problem were experiencing both concurrently. It highlighted that “People living with this mix of difficulties are discriminated against and are often judged and marginalised from services and the community”.7

Law enforcement agencies, including the courts, are common points for identifying users of crystal methamphetamine and other illicit drugs and for referring these people to treatment. This includes pre-arrest and arrest stages, and court- and sentence-based orders (all states have court-supervised treatment programs for users of illicit drugs). The focus is on illicit drugs, not alcohol. Only two states have treatment units for short-term involuntary “care and control” of severely substance-dependent people whose survival is at risk. Mental Health Acts deliberately exclude the effects of drugs and alcohol from the definitions of mental illness. A person manifesting features of a mental illness that are attributable to substance misuse can be held only for a temporary period as a “disordered” patient. Once discharged from care, primary health care workers may be faced with treating such patients in an environment that has scarce on-the-ground drug and alcohol services.

Three issues in current drug and alcohol policies stand out for resolution: substance misuse problems must be recognised as inherently “people” problems, not solely problems of pharmacology; legislation centred on drug law enforcement must be shifted to a public health framework based on reducing harm from misuse of all drugs; and management of drug and alcohol misuse needs to become a mainstream task for all health services. Accordingly, the nascent Primary Health Networks should be resourced to respond to region-specific drug and alcohol problems, and to work in partnership with specialist drug and alcohol services. To enable this, the speciality of addiction medicine should be recognised by the federal government. Finally, with increasing recognition of the co-occurrence of mental health and substance misuse problems, the historical separation between mental health and drugs and alcohol needs to be re-thought, and new approaches devised.

“Ice” (crystal methamphetamine): concerns and responses

There is no cause to feel impotent, despite disturbing media reports about methamphetamine

Methamphetamine has been around for some time. Although it is now available in a crystal form that is more potent and more readily smoked than earlier forms, no-one should feel impotent in the face of widespread alarmist commentary about this drug.

The recent National Ice Taskforce Report1 describes a pattern of increasing use of methamphetamine over the past decade. Compounding the effect of the shift in use from the older amphetamine sulphate to methamphetamine (in powder or crystal form) is the increase in purity of illicit methamphetamine: the purity-adjusted price (the dose obtained for a given price) is now similar for both methamphetamine forms,2 so that users obtain much larger doses. This probably underlies the evidence of more regular and greater levels of dependent use among people who use the drug, and also some of the increases in observed harms.3

The medical profession is pivotal in responding to these changes, and needs to provide clear, evidence-based responses and care for those affected; it is not “someone else’s problem”.

People who use methamphetamine come into contact with the general health care system for a number of reasons, ranging from problems directly related to use (eg, insomnia, acute mental health problems) to complications of use (eg, injuries, infections and cardiovascular problems), some of which may be detected while providing other care (eg, during antenatal care). Some users present when seeking treatment from general practitioners, including some requesting benzodiazepines or other sedatives, but methamphetamine use may not be disclosed or the GP may not have asked about it; sometimes it is other members of the family who seek help.

People who use methamphetamine are generally younger (under 40 years of age); more men than women use these drugs, and users commonly experience mental health and other substance use problems.4 Use is more prevalent among some groups more frequently exposed to health risks, especially Aboriginal and Torres Strait Islander people, and the gay, lesbian, transgender and transsexual communities. Recent use is more common in rural and remote communities. Most people who have used methamphetamine have done so only occasionally; however, the best available data suggest that there are now more regular and dependent users of the drug than at any other time in the past decade.5

What would be an appropriate response? There is a pressing need for a flexible and coordinated treatment system that can respond in a timely manner to people who use amphetamines. We need to develop the skills, confidence and capacity to do so. Drug and alcohol specialists, nurses, psychologists and other allied health practitioners all play key roles in partnership with primary and acute care services, including emergency departments and mental health services. Strategies to engage the broader medical workforce are urgently needed. GPs cite a range of reasons for feeling unskilled or unsupported in managing people with substance misuse problems, so that many are reluctant to do so.6 This situation must be changed if we are to improve our frontline responses to problems linked with methamphetamine use.

Optimal alcohol and drug-specific treatments incorporate multidisciplinary care that also attends to co-occurring substance use (eg, tobacco), as well as to physical, mental health and social problems. Psycho-social treatment approaches include specific drug counselling and support, withdrawal services, day programs and residential treatment for those who require more intensive support. Assertive follow-up and proactive relapse prevention programs are crucial, as the relapse rate among dependent methamphetamine users is high.

More research is needed to develop methods for better attracting methamphetamine users to treatment, to provide brief interventions for those with less severe problems, and to improve treatments for those who need intensive assistance. In addition to ongoing research overseas, a recently announced NHMRC grant to fund research that explores an alternative pharmacotherapeutic approach (application 1109466) and another that will examine the particular needs of Aboriginal communities (application 1100696) are promising starts.7

The alcohol and drug treatment sector needs to grow significantly to allow it to respond to those who need intensive treatment and to be available to support primary care. The announced introduction of Medicare item numbers for addiction medicine specialists8 will facilitate development of the workforce in this area. The use of a national planning model that assesses needs according to population prevalence, estimates the demand for treatment, and calculates the amount of resources required to respond effectively has been used to develop mental health services. A similar plan should be a matter of priority as a blueprint for national drug and alcohol service development.9 Western Australia has used modelling to develop one version of such an approach, focusing on system integration because this “ensures service delivery is comprehensive, cohesive, accessible, responsive, and optimises the use of limited resources”.10

The release of the Final Report of the National Ice Taskforce provides an opportunity for action. However, many key issues raised in the report still require adequately resourced strategies; this applies especially to specific plans for Indigenous communities. Mixed funding by the federal and state governments makes it challenging to achieve the necessary coherence of response. The Primary Health Networks will need to rapidly develop the capacity to engage with GPs, and specialist drug and alcohol services if they are to play a key role. Governments, health services and the general community must seize this opportunity to respond to the problems associated with methamphetamine use.

6 procedures and tests that should be questioned: physiotherapists

The Choosing Wisely campaign will reach the next stage in mid-March with the release of their next wave of recommendations from Australian medical colleges, societies and associations.

The campaign kicked off in 2015, with the Australasian College for Emergency Medicine, the Australasian Society of Clinical Immunology and Allergy, The Royal Australian College of General Practitioners, The Royal Australian and New Zealand College of Radiologists and The Royal College of Pathologists of Australasia all releasing their recommendations of tests and treatments to question.

In the next few weeks, the next wave of colleges will release their recommendations, including a second list from the RACGP.

In anticipation of the announcement, the Australian Physiotherapy Association has developed a list of 6 recommendations that clinicians and consumers should question. It is the only allied health profession among twelve medical colleges and societies taking part in Choosing Wisely.

They say their recommendations are not prescriptive and should merely help start a conversation about what is appropriate and necessary in each individual situation.

Related: Richard King: The right choice

Their list is:

Don’t request imaging for patients with non-specific low back pain and no indicators of a serious cause for low back pain.
Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated decision rule.
Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules, (localized bone tenderness or inability to weight-bear as defined in the Rules).
Don’t routinely use incentive spirometry after upper abdominal and cardiac surgery.
Avoid using electrotherapy modalities in the management of patients with low back pain.
Don’t provide ongoing manual therapy for patients with adhesive capsulitis of the shoulder.

The six recommendations were collated from a member survey with around 2800 responses, which was then examined by an expert panel.

Latest news:

AMA in the News – 23 February 2016

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

AMA attacks health insurers’ clawback, Adelaide Advertiser, 5 February 2015
Private health insurance customers could finally see a slowdown in the rate of premium rises, amid criticism of insurers for scaling back members’ entitlements. AMA President Professor Brian Owler accused some insurers of scaling back members’ coverage.

Sticking up for all children, Northern Territory News, 8 February 2016
The AMA wants all children who fall behind on their vaccination program to be allowed to catch up for free, calling for further Federal Government funding to boost immunisation rates. AMA President Professor Brian Owler said Government claims that health spending was unsustainable were not backed by evidence.

Medicare plan risks privacy, Adelaide Advertiser, 12 February 2016
A private company would know whether a patient had an abortion, herpes or was getting mental health treatment if the Government proceeds with a plan to privatise Medicare and medicine payments. The AMA is calling on the Government to change the system so a patient’s Medicare rebate could be assigned directly to the doctor.

Anti-vax nuts crack at last, The Sunday Telegraph, 14 Februay 2016
Almost 260 extra children are being immunised every week as even the most hardened anti-vaccine fanatics change their view. AMA President Professor Brian Owler said people are starting to realise the anti-vaccination lobby does not hold weight, and some of the policies are starting to take effect.

Indigenous health vital, The Herald Sun, 18 February 2016
AMA President Professor Brian Owler, in Alice Springs visiting health groups and clinics, said the Closing the Gap report, released last week, indicated that health had fallen off the radar.

Bulk-billing on the rise despite mooted cuts, The Australian, 19 February 2016
Bulk billing rates have continued to rise despite health groups warning patients will be left out-of-pocket because of a Federal Government freeze on Medicare rebates. AMA President Professor Brian Owler said the plan to remove the bulk billing incentive from pathology services was a sign the co-payment had risen from the grave.

Radio

Professor Brian Owler, 666 ABC Canberra, 8 February 2015
AMA President Professor Brian Owler discussed the AMA’s Pre-Budget Submission. Professor Owler criticised the Federal Government for telling basic ‘untruths’ about health spending.

Dr Brian Morton, 2GB Sydney, 9 February 2016
AMA Chair of General Practice Dr Brian Morton discussed homeopathy. Dr Morton said he was concerned that people who chose homoeopathy might put their health at risk.

Professor Brian Owler, ABC News Radio, 11 February 2015
AMA President Professor Brian Owler talked about health spending and the MBS Review.

Professor Brian Owler, ABC South East NSW, 15 February 2016
AMA President Professor Brian Owler discussed hydrocephalus. Professor Owler said shunt registry for hydrocephalus could be used as a quality assurance tool in order to decrease blockages and infections which affect morbidity and increase costs to the health system.

Television

Professor Brian Owler, ABC News 24, 28 December 2015
Landmark legislation will be introduced into Parliament to legalise medicinal cannabis. AMA President Professor Brian Owler said medicinal cannabis should be regulated in the same way as other narcotics.

Professor Brian Owler, CNN, 16 February 2016
AMA President Professor Brian Owler slammed Government policy on asylum seekers. Professor Owler said doctors who work with asylum seeker children face an incredible ethical dilemma, because they cannot allow children to be discharged into an unsafe environment.

Professor Brian Owler, SBS Sydney, 17 February 2016
Prime Minister Malcolm Turnbull said there would be no change to Australia’s border protection policies despite an offer from New Zealand Prime Minister John Key to take in children headed for offshore detention. AMA President Professor Brian Owler said this was a complex issue, but the issue facing the AMA is to ensure the health care of asylum seekers and getting children out of detention.

Govt funding goes begging because of bungling

The Health Department has been accused of bungling a multi-million dollar program intended to boost GP training in rural areas.

AMA President Professor Brian Owler has taken the Department to task over revelations that fewer than 50 Rural and Regional Teaching Infrastructure Grants have been awarded, despite funding for double that number.

In its 2014-15 Annual Report, the Department advised that just 10 of 100 grants provided for by the Government in that year had been approved. Professor Owler said that since then a further 38 had been awarded, and negotiations on another “20 or so” were underway.

But the AMA President said this still fell well short of expected targets. In its 2014-15 Budget, the Government committed $52.5 million over three years to fund at least 175 grants worth up to $300,000 each.

There are ongoing concerns about the difficulty of recruiting and retaining doctors to practise in country areas, and the grant program was established to help rural clinics to expand their facilities to accommodate medical students and supervising GPs.

Professor Owler said the program’s underperformance was particularly disappointing given the Government’s crackdown on spending in most areas of health.

“Many health services and programs and organisations are struggling as the Government puts the Budget bottom line ahead of improving health outcomes,” he said. “So it’s a surprise to find an area of health where funding targets are not being met or, to put it another way, precious allocated health funding is not being spent.”

The AMA President said the implementation of the program had been flawed – it took the Department four months to invite applications, and set a deadline during the 2014-15 Christmas-New Year holiday period.

“Give the Department’s extensive experience with infrastructure grants, this should have been a straightforward exercise. Clearly it has bungled the process,” Professor Owler said. “This ineptitude has wasted a rare opportunity to enable more medical students and GP registrars to experience and develop an interest in rural practice, and give patients better access to health services in their community.”

He said that what made it all the more galling was that this had occurred at a time when the Government was slashing GP funding.

The episode also showed the destructive effect of health spending cuts.

Professor Owler said the financial uncertainty created by Government policies such as the Medicare rebate freeze and the MBS Review had made general practices increasingly risk averse.

In order to qualify, practices have to commit to matching the grant provided by the Government, and the AMA President said many were reluctant to make the investment in the current environment.

He said it was unsurprising that, given the lacklustre response, the Government was reconsidering its approach to infrastructure grant funding.

Adrian Rollins

Department giving GPs the PIPs

The Health Department is threatening to axe incentive payments to medical practices that fail to upload shared health summaries to the My Health Record system despite the fact that it is still under development.

In a move condemned by AMA Council of General Practice Chair Dr Brian Morton, the Department has advised general practices that unless shared health summaries for 0.5 per cent of their standardised whole patient equivalent are uploaded in May, they will no longer be eligible for payments under the e-health Practice Incentives Program (ePIP).

A Department spokeswoman told Pulse+IT magazine the eligibility requirement could be met by a single GP in the practice, and added that a tiered performance-based approach linked to levels of system use would be introduced from August, “subject to the outcome of consultations with the general practice community”.

But Dr Morton condemned the Department’s move, which he said was premature and had been undertaken without adequate consultation.

“It’s going to be an appalling cock-up because they haven’t listened to the profession, they’ve not listened to the stakeholders, and they’re not giving us enough time,” he told Medical Observer.

The Department is implementing the new eligibility requirements even though a trial of My Health Record’s opt-out arrangements is not due to commence until mid-July, and numerous privacy issues have yet to be resolved.

“They should be holding off until the pilots have been run and the opt-out has actually happened,” Dr Morton said.

The AMA has long flagged serious concerns with the approach the Department is taking to implementing the My Health Record (MyHR) system, which is intended to supersede the flawed Personally Controlled Electronic Health Record.

In a submission to the Health Department last year, the AMA argued that fundamental issues with the design of MyHR had to be resolved before any move to links its use to the ePIP.

It said that until shortcomings of the PCEHR such as incomplete and hidden information and a lack of take-up among consumers were fully addressed, it was premature to try to force doctors to adopt it.

“Until these problems have been rectified MyHR is neither a meaningful or functional tool, and it is unreasonable to expect GPs to actively use it,” the AMA said at the time.

“If the MyHR is easy for practitioners to utilise, the information it contains is reliable, the system and record transparently interoperable, and practitioners can quickly and clearly recognise how it will enhance patient care then they will readily engage with it.

“However, we know that the MyHR is none of these things and using the PIP incentive to try and mandate use of the MyHR will not solve this.”

The AMA said that, rather than a single practice-level ePIP payment, a better way to encourage GPs to use the system was to remunerate them through an MBS item or a Service Incentive Payment (SIP).

Adrian Rollins

[Perspectives] Social medicine: lessons from Cuba

Midway through my third year of medical school, I had a class session to discuss the changes that would result from the US health-care reform bill. The lecture was part of our school’s attempt to educate us on the policies that would affect our careers. The session had only just begun when a classmate remarked, “I just want to know how much I’m going to get paid.” Laughter swept through the room, leaving only a few people looking surprised. Soon after, another classmate, a self-proclaimed future orthopaedic surgeon, raised his hand and asked, “Why are we paying primary care doctors more?” He went on to argue with one of the speakers, an up-and-coming primary care doctor, and insisted that the latter’s job would soon be replaced by nurse practitioners.

RACGP launch first draft of standards for general practices

The Royal Australian College of General Practitioners has launched their first draft of the fifth edition of the RACGP standards for general practices.

The aim of the standards is to keep pace with the changing environment and support patient safety in contemporary general practice.

The RACGP are urging GPs, practice staff and other stakeholders to read the standards and participate in the consultation.

“This first draft consultation is just that – a draft of what is a multifaceted set of requirements – and it is an opportunity for all involved in general practice to put forward their thoughts and perspectives in order to shape future drafts and the final version,” RACGP President Dr Frank R Jones said.

Dr Jones hopes some key additions to the latest draft will spur debate amongst the GP community.

“Some of the new proposed Indicators relate to the use of defibrillators in general practice, documentation of a third party in the patient’s medical record, changes to patient feedback requirements and developing a practice strategy for planning and setting goals,” Dr Jones said.

Other key changes to the edition includes a focus on outcomes and patient focused indicators.

Some of the suggestions for new indicators and newly mandatory indicators include:

Our patients can access resources translated into a language in which they are fluent.

The standards suggest having a directory of resources, services, online tools and websites that facilitate or provide resources that translate information into languages other than English.

Our patients can access up to date information about the practice. At a minimum, this information contains information on the range of services we provide

This could be done through a website or information sheet with pictures and simple language for patients who may not be able to read or understand the information.

Our patients are informed of the out-of-pocket expenses for health care they receive at our practice and potential out-of-pocket expenses for referred services

For some patients, the cost of treatment and investigations could be a barrier to care so providing information before they begin potential treatments to help them make an informed decision. If the patient indicates cost is a barrier, discuss potential alternatives such as referral to public services.

Our clinical team considers ethical dilemmas

Situations such as end of life care, pregnancy termination and receiving gifts from patients can all be ethical dilemmas. Practices need a process to resolve ethical dilemmas in a timely way.

Our patients receive information on health promotion, illness prevention, and preventive care

Health promotion is distinct from education and helps patients improve and increase their control over their health.

Our clinical team can exercise autonomy in decisions that affect clinical care (this is now mandatory)

Practitioners can use their knowledge of evidence and their credentials to determine the appropriate clinical care for each patient and decide which specialists to refer a patient to, which investigations to order and how and when to schedule follow-up appointments.

Our practice has a policy on the use of email and social media.

The policy should contain information about password security, updating email addresses and obtaining patient consent to communicate with them via email.

Our clinical team is trained to use the practice’s equipment

Keep a training and development calendar and training log to ensure all clinical and non-clinical staff have completed the appropriate training for the practice’s equipment.

Our practice seeks feedback from the team about our quality improvement systems and the performance of these systems

Giving all members of the practice team a chance to provide feedback gives the practice team the opportunity to consider how the practice can improve.

Our practice team undertakes activities aimed at improving clinical practice

Collecting clinical data can help improve practice care but helping with practice audits, PDSA cycles and using processes to identify patients with particular medical conditions

Time-critical results identified outside normal opening hours are managed by our practice

The practice needs to have procedures in place to ensure timely receipt of seriously abnormal or life-threatening results when received outside opening hours.

Our practice initiates and manages patient reminders

Our practice tracks and logs the patients on which reusable medical instruments have been used

The practice needs to be able to trace patients and track reusable medical devices in case there is failure to follow up on sterilisation or a medico-legal issue related to sterilisation.

Our practice team is aware of the risks associated with equipment use

Our practice has a defibrillator

This is not mandatory. The standards team specifically ask whether stakeholders believe they need an automated external defibrillator (AED) in their practice.

Consultation on this draft will run until 1^st April 2016 with the final version expected to be officially launched in October 2017.

To read a copy of the draft, visit the RACGP website.

Latest news:

Government faces ballot box pain if no policy shift

The Federal Government could pay a hefty price at the ballot box unless it changes course on health policy, the AMA President Professor Brian Owler has warned.

As senior Ministers thrash out details of the all-important pre-election Budget behind closed doors, Professor Owler cautioned that how the Government responds to the many reviews it has commissioned across health, particularly regarding Medicare, primary health and private health insurance, “may well have a significant electoral impact, especially if key health stakeholders are not properly engaged”.

Professor Owler called for a fundamental shift away from the Government’s current emphasis on cutting spending and offloading the funding burden onto patients and the states and territories.

“The Government is on a path of funding cuts and shifting costs to patients,” the AMA President said. “This is not good for the Australian health system or the health of Australians.

He urged it to “change tack…before it is too late”, warning the Government its current approach might m.

Professor Owler’s comments framed the AMA’s Pre-Budget Submission, which includes detailed recommendations across 18 areas of health policy, from Medicare indexation and reform of hospital funding to GP infrastructure grants, palliative care, alcohol and tobacco policy and immunisation.

The AMA President said the submission gave the Government a guide on how to recalibrate its policy to end the current retreat from core responsibilities in funding and delivering health services.

“There is an urgent need to put the focus back on the strong foundations of the health system,” Professor Owler said. “We need a strong balance between the public and private system, properly funded public hospitals, strong investment in general practice, and a priority put on prevention.”

There are already signs that Government decisions are having an adverse effect on health services.

The AMA Public Hospital Report Card released in late January showed that improvements in hospital performance have stalled, and in some instances have gone backwards, since the Government’s decision to 2014 to rip hundreds of millions of extra funding out of the system.

Professor Owler said the cuts, combined with a downshift in the indexation of Commonwealth hospital funding from next year, showed the Government’s preoccupation with funding cuts came at the expense of good health policy.

The Government’s response to the mental health review provided more worrying signs of how it might approach other areas of reform, he said.

Under the new approach, Primary Health Networks will be paid by the Commonwealth to provide tailored “integrated care packages” for patients with mental health problems.

Professor Owler said there was no commitment to a key role for GPs in providing care, and the Government had provided scant other detail.

“The worry is that the mental health approach may be a signal for what is to come with the Primary Health Review,” he said, and added that a proposal for hospital funding to be replaced by a Medicare-style “hospital benefit payment” that would follow patients was also a worrying sign.

The AMA President said the Government had actively demonised doctors in its MBS review process, had encouraged private health funds to play a more active role in all areas of health despite concerns over inappropriate behaviour and poor value products, and showed signs of pursuing a US-style managed care system.

He warned that “this is not a health policy platform to take to a Federal election”.

In its 27-page Budget submission, the AMA proposed the Government immediately reinstate indexation of Medicare rebates; increase indexation of public hospital funding to a rate that reflects growth in the cost of health goods and services; recognise the both the Commonwealth and the state and territories all have a role in funding and providing health services; explicitly address the role of the private sector in delivering care; and give patients the right to assign their Medicare benefit direct to the provider.

Professor Owler said the nation needed a health system built on “modern health policies, not outdated economic policies designed only to improve the bottom line”.

Adrian Rollins