The Importance of the Home GP
According to new data released by the Australian Institute of Health Welfare (AIHW), nearly 50% of all Australians suffer from one chronic medical condition, while 20% suffer from at least two. These figures include cancer, respiratory, cardiovascular, musculoskeletal, rheumatological, endocrine and mental health conditions. Unsurprisingly, they are the leading cause of illness and disability in Australia, accounting for 90% of all deaths in the most recent statistics from 2011. In this context, chronic disease is becoming well entrenched as the greatest struggle facing an overloaded health care system.
Notably, it is placing a significant burden on the health budget, with governments of both political persuasions grappling with the soaring costs. Conservative estimates of allocated health-care expenditure indicate that the four most expensive disease groups are chronic, and when combined, consume 36% of the total allocated health budget. As such, the management of chronic diseases has driven the need for more efficient and effective initiatives to be implemented.
I believe the discussion should focus on how more responsibility can be given to GPs to relieve the burden on hospitals, and what measures can be taken to facilitate this transition.
Under the Abbott Government, attempts aimed at finding savings within the general practice, such as the much-maligned GP co-payment, have angered both health professionals and patients, deterring patients from visiting their local GPs except for acute circumstances, and in effect undermining the overall management and prevention of treatable chronic conditions. More optimism lies under the Turnbull Government, who in the recent 2016 budget has introduced a variety of measures such as the Health Care Homes trial, which aims to shift the responsibility for managing of chronic conditions from hospitals to general practices.
While this is overall a step in the right direction, I believe that the shift in responsibility should be accompanied by other incentives and compensations to GPs, to alleviate the extra burden of care while also guaranteeing quality of practice. GPs are instrumental in managing chronic conditions. However, their capacity is strongly correlated with their rapport and understanding of their patient.
One in six Australians sees more than 3 health professionals for the same health condition. This concept of “doctor shopping” actually has two main disadvantages. The first is the inefficient utilisation of Medicare that occurs when “anonymous” GPs struggle to elicit the full clinical picture, and subsequently feel pressured to order extra tests or prescribe unnecessary treatments in the absence of more pertinent background history. As Avant’s Senior Medical Advisor Dr Walid Jammal says: “Doctors are stuck. It’s like they’re prescribing blind”.
This is in contrast to “home GPs”; general practitioners who see their patient on a regular and consistent basis. They have a better and more thorough understanding of their patients’ medical history, and are more equipped to know what investigations or resources are required to manage their individual circumstances. The second problem is that patients who see “anonymous” GPs feel less “responsibility” or “obligation” to take care of their health, and this sentiment flows back down to the doctor, who may feel disinterested in organising thorough management goals and plans if they anticipate non-compliance. If both patient and doctor are in a lasting professional relationship, a sense of trust is implicitly generated, and the patient may feel more responsible to “take charge” of their health such as embracing lifestyle modifications and ensuring strict compliance with medications.
Given the advantages of a “monogamous” patient-doctor arrangement, it would be worthwhile considering measures to encourage patients to enrol with a single GP practice. In its Health Care Homes package, the Government has already implemented the recognition of a “nominated” GP who is “aware of [the patient’s] problems, priorities and wishes, and is responsible for their care coordination”. This GP becomes the main point of contact for the patient, and is responsible for developing a tailored care plan for their management. It has also introduced incentives for doctors to take on patients with chronic conditions, such as the Practice Incentive Program and Service Incentive Payments for clinics that take on the management of diabetic patients. However, these measures are limited to only the correspondence and continuation of care of said conditions. In his submission to the Medical Observer, practising GP Guy Campbell advocates for the more proactive pay-for-performance (P4P) model:
- Premium rebates for nominated GPs (as opposed to lifting the rebate freeze on all GPs)
- Outcome incentives for nominated GPs only: rewarding GPs who can demonstrate that they improve patient outcomes, for example possibly by lowering HbA1c levels in diabetic patients, a test that reflects blood sugar level control
By doing so, nominated GPs will feel empowered to improve the health of their patients by having tangible targets to strive for, as well as financial recognition for the better services that they provide compared to anonymous GPs. At the same time, anonymous GPs – feeling the brunt of the rebate freeze plus the denial of outcome incentives – have less incentive to see casual patients, and may feel compelled to charge a co-payment when they do to meet the shortfall. This carrot-stick approach is thus designed to effect a gradual societal change towards embracing the notion of “home GPs”.
This pay-for-performance model is already in place in the UK, introduced in 2004 as the UK Quality and Outcomes Framework (QOF), a comprehensive national primary care P4P. A systematic review published in the Annals of Family Medicine (AFM) concluded that while there has been observed modest improvements in the quality of care for chronic diseases, as well as the consolidation of evidence-based practice in the workplace (as part and parcel of qualifying for the incentives), the impacts of cost, professional behaviour and patient experience remains uncertain. Similar sentiments are echoed in a longitudinal survey conducted by the MJA, which found that the large administrative burden of claiming incentives may not outweigh the benefit, relative to the size of the payment. Lastly, directly linking health outcomes to financial incentives may raise legitimate ethical concerns, calling into question whether an incentives-based model could adversely affect the clinical practice of a doctor. Inappropriate over-treatment or prescription of more potent medications with harsher adverse effects not only leads to a wasteful allocation of limited resources, but at worst potentially endangers the patient’s health.
The AFM rightly recognises that more research should be conducted in this area, looking into whether an improvement in quality of care can be consistently and affordably achieved, while investigating ways of reducing the unintended adverse effects of such measures. While implementing P4P schemes will put an immediate strain on the budget bottom line, shifting the responsibility of chronic care from the hospital to the general practice is imperative for efficient functioning of the health-care system. This will inevitably reduce the financial burden on hospitals in the long run due to the reduced frequency of exacerbations and admissions that come with better control of chronic medical conditions. In this case, long-term gain should be sought at the expense of short-term pain.
The views and opinions expressed in this article are those of the author and do not necessarily represent those of the Doctus Project.