Government flags shift in fee-for-service model

Jolyon Attwooll

23/01/2023 4:29:03 PM

Minister says reforms will involve every health professional ‘working to their scope of practice’, while RACGP stresses importance of GP stewardship.

Health and Aged Care Minister Mark Butler
Health and Aged Care Minister Mark Butler has said the Strengthening Medicare Taskforce report will be released shortly. (Image: AAP Photos/ MICK TSIKAS)

Proposed Medicare reforms are likely to reduce the reliance on the fee-for-service patient rebate system, the Federal Government has indicated.
In comments published in The Australian, Health and Aged Care Minister Mark Butler said the current system will be ‘in real trouble’ without change.
‘Medicare is an utterly central pillar of our healthcare system, but what is pretty clear to me is that the MBS [Medicare Benefits Schedule] rebate model, and Medicare funding more broadly, isn’t working for the disease profile the country now has: an older population with much more chronic disease,’ he said.
‘It really is a system that was designed for much more linear episodic care that was more the state of things in the 1980s and 1990s.
‘And at a time of skyrocketing patient demand and workforce shortages, it just doesn’t make sense not to have every health professional working to their scope of practice.
‘We need doctors working hand in glove with practice nurses, allied health professionals and pharmacists. The system is not well designed to allow them to do that.
‘Clearly an expansion of multidisciplinary care is key to managing chronic disease.’
Appearing in front of the media on Monday, Minister Butler noted that the average gap fee is now more than the Medicare rebate and said reforms will be designed to ease pressure on ‘an already very, very stressed hospital system’.
As well as greater team-based care The Australian article suggested voluntary patient enrolment and an overhaul of digital health communication are likely focal points in the Taskforce report, which Minister Butler indicated would be released in the next couple of weeks.
He said that changes involving less reliance on fee-for-service have been considered for some time.
‘The idea of moving from a purely fee-for-service model that has largely defined Medicare over the last 40 years to something that’s more blended, that has more wraparound funding particularly for older patients and patients with complex chronic diseases, is not a new idea,’ he said.
‘This has been discussed for many years. We had pilots when we were last in government, particularly in the area of diabetes.’
For RACGP President Dr Nicole Higgins, the emphasis on multi-disciplinary care for patients is welcome, with the caveat that it must be under the stewardship of GPs.
‘General practice is in crisis after decades of under-funding – and we need to stem the bleeding,’ Dr Higgins told newsGP.
‘But we need a huge shift to do it, with bulk billing incentives so everybody gets the care they need regardless of where they live, and longer consultations rewarded to reflect more complex care.
‘We know our patients best, and general practice is the most cost-efficient part of our health system.
‘We are also fighting tooth and nail to see off threats to the viability of general practice like the proposed payroll tax. 
‘The biggest threat to Medicare reform is payroll tax. This is a tax on Medicare. This will kill bulk billing.’
Prime Minister Anthony Albanese also addressed healthcare in an interview on Monday, telling Sunrise that the Government is considering models of primary care designed to take the pressure off hospitals.
He referenced a $100 million funding commitment, announced in the October Budget for a trial ‘to co-develop and pilot innovative models with states and territories to improve care pathways and inform the urgent care program rollout’, and said he would have ‘more to say about that in coming days’.
Dr Higgins says getting that model right will be crucial.
‘It is essential we focus on the healthcare models that work,’ she said.
‘Medicare is a precious resource and we don’t want another NDIS with cost blowouts and fragmentation of care.
‘We know an NHS type model, which is trading continuity of care for access does not work, nor does the US model, which doesn’t have the patient at the centre.
‘One of the best models, with the happiest and the healthiest healthcare systems, is in Denmark, which is 70% fee for service, and 30% block funding, where the GP leads a multidisciplinary care team.’
Last month, the Grattan Institute thinktank put forward a suggested model recommending a system based on 70% on capitation and 30% on fee-for-service in an analysis Dr Higgins described at the time as a ‘disappointingly simplistic take on a very complex problem’.
The details of the new model are yet to be finalised, with the Strengthening Medicare Taskforce report likely to give broad consensus recommendations that all its participants – a broad cross-section of healthcare and advocacy groups, including the college – can agree upon.
Block funding budgets to practices to help them employ allied health workers and fund services such as diabetes prevention initiatives is one option being considered, along with direct incentive payments to clinics.
The discussion comes at a pivotal time for healthcare in Australia, with Minister Butler reiterating a commitment to Medicare reform which he described as ‘a centrepiece’ of the Government’s platform for last year’s election.
Earlier this month state government leaders also made a plea for urgent change. Victorian Premier Daniel Andrews and his NSW counterpart Dominic Perrottet both stressed the need for greater collaboration between different levels of government and identified healthcare reform as ‘a priority’.
Their calls came ahead of a National Cabinet meeting due to be held on 1 February, in which healthcare is believed to be a key item for discussion.
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Dr Paul Michael Coughlan   24/01/2023 7:49:42 AM

Looks like an unfriendly climate for small and single handed practices.

Block funding comes with heavy reporting requirements.It is difficult for smaller practices to carry large work forces. We have seen this before in the era of The Collaboratives .Spiralling expenses when Practice Nursing rebates cut . And please Mr Butler , will all these Allied Health folk be contractors , or employees .Or is the tax strategy part of a pincer movement.

Dr Charles Rhee   24/01/2023 9:37:29 AM

Another blow for General Practice. This will lead to increases in red tape and bloated bureaucracy with virtually no meaningful additional funding. I am sure that the move to abandon bulk billing will gain pace and we will join our colleagues in other specialties in private billing most patients.

Dr Bradley Arthur Olsen   24/01/2023 10:17:53 AM

Say goodbye to after hours , fee for service care. Be ready for practices to cover their patients 24/7. For us older than 60 , get ready for full retirement rather that part time work to help those younger GPs with families

Dr Peter James Strickland   24/01/2023 11:54:32 AM

Remember that this govt. is Whitlam in new shoes, and is on the road to economic disaster. Hospital funding deficiencies are directly related to "free" medicine for expensive non-hospital ED consults. Dramatically increase the GP rebates, and charge non-urgent patients in hospital EDs for consultations. People are used to "free' healthcare --someone has to pay, and that is the taxpayer. If everyone contributes something to their healthcare there is a solution in sight; otherwise, we are heading for the NDIS dilemma happening right now with exploitation and out-of -control costings going NOT to patients, but administration, public servants, lawyers etc. The pre-Medibank and Medicare era worked well, and now slow disintegration has happened for 50 years due directly to Whitlam-type socialism destroying general practice especially by over-adminstration (mainly by public servants) and their ministerial bosses totally incompetent in good community medicine funding and administration

Dr Stephen H   24/01/2023 1:01:00 PM

Well, that's it, our practice will no longer be bulk billing pensioners etc. We have held off making that difficult decision pending the promised "strengthening" of Medicare but given that "Mark Butler says government won’t add ‘more money to the existing system’ despite calls from doctors for urgent extra funding" (I'm not surprised the RACGP here is quoting the positive -spun Australian reporting rather than the negative-spun Guardian) we clearly cannot expect any meaningful support and will need to charge our most vulnerable or go out of business. Once again the RACGP has proved useless in the face of other lobby groups/narratives - including the one that "paying doctors more – without adjusting other settings – could result in some GPs offering fewer services because they could make more money in less time" - basically we should burn out to keep the lights on.

Dr Brendan Sean Chaston   24/01/2023 1:37:37 PM

Medicare is not a bad system. It was defunded and ruined by the rebate freeze. Resume previous funding and return to how it was prior. Australia has an excellent healthcare system. Why experiment with different models which probably will be worse. Unfortunately quality in anything costs money.

On a separate point I don’t think it’s fair to encourage any potential candidate to pursue general practice training currently. You could be doing them a real disservice. My take on the proposed models is further devaluing of the role of the GP.

Bilal Khan   24/01/2023 5:21:49 PM

Again dodging the main issue. Underfunding. Increase medicare rebates by 50% . That is all . We will look after our patients better.

Rural GP   24/01/2023 6:04:03 PM

This is a chilling message for an older GP who embraced a strong independent profession of General Practice, based on a fee for service model. The messages are clear, we will take your initiative and compassion and you will work for the government now. You will fit in and shut up, or else privately bill and watch the system burn. I predict bulk billing incentives will change nothing, they can never force after hours or wholistic care. That relies on General Practitioners themselves. We just want a true fee to recognize our service, then we can strengthen Medicare . Could these politicians and advisors be any more misguided and arrogant. ?

Dr Nicholas Kunzer   24/01/2023 7:38:16 PM

How to implement a performance incentives model that takes into account the fact that most GPs are contractors with their own patients is yet to be seen. In HMO models it’s easy when all the doctors are employees and organisations are big enough to collect and utilise their data in meaningful ways. Will the PHNs have a similar role collecting data and setting targets for GPs and practices that take in to account the variety of practices currently out there? Looking forward to seeing a detailed model that appeals to new GPs and those looking to join general practice

Bilal Khan   25/01/2023 4:55:15 PM

Again dodging the main issue. Underfunding. Increase medicare rebates by 50% . That is all . We will look after our patients better.

Dr Abdul Ahad Khan   28/01/2023 12:37:37 PM

It is sad to see my GP Colleagues pleading for MC Rebates to be increased.
The MC Rebate is NOT meant for GPs .
The MC Rebate is only a Subsidy given to the more than 99% of our Populace, in order to assist them pay the FULL FEES charged by their GP.

As we have seen, a CRY from us GPs ( GPs constitute less than 1 % of our Populace ) has always fallen on Deaf Ears.
But, a CRY from the other more than 99% of the Populace, that the MC Rebates that they are receiving from the Govt. is grossly inadequate will never be ignored by any Political Party.
My Appeal to my Fellow GPs :
* Stand up with Dignity & charge a Fees befitting a GP
* Leave the Crying & the Pleading to the other more than 99% of the Voting Populace,
that the MC Rebates that they receive for a GP Consult is grossly INADEQUATE.

We will then see the Political Party currently in power & the Opposition Parties attempting to outbid each other in raising the MC Rebates for us Hard-working GPs at the Coal-face.

Dr Simon Holliday   28/01/2023 12:51:10 PM

A couple of responses:
Firstly, Butler will be aiming to fund and regulate GPs working to their scope of practice. Presumably this means GPs become care coordinators or gate-keepers. Both these roles surely could be done cheaply by trained RNs.
On the other hand, GPs have the skills (or we used to before being de-skilled) to provide most acute and chronic care including much emergency or in-patient care. What a waste to not utilise GP's skill-sets in order to make health care more geographically accessible and cheaper to patients and the tax-payer.
The other point is that Premiers Andrews and Perrottet should earn an Oscar for keeping a straight-face while calling on the Commonwealth to increase access to bulk-billing GPs. What hypocrisy for at the same time their state revenue departments are firing off salvoes of payroll tax to destroy quality care now and, by taxing GP training, in the future.

Dr Muhammad Navaid Ahmed   14/11/2023 10:43:16 PM

I have worked in similar systems like MyMedicare in the UK and I can tell you, this will lead to disaster and nothing else. Increasingly taking more and more ownership of patients will come at a very hefty price in the long run, more red tape, reporting requirements, workload, dumping of chronic and complex illness on us, services and billing audits, etc

The plan is to eventually offer block payments for services replacing the current fee-for service item numbers and believe me in the long run we will be worse off, well may be not owners but we the Drs, as we will get replaced by far cheaper noctors and pocters! (nurses and pharmacists). Mark my words its cost cutting move by the govt aimed at buying cheaper healthcare in blocks, putting more responsibility (and blame) on drs, exerting more control and forcefully access our data pools. It might become ''all you can eat buffet'' for patients and we will get peanuts in return.