Would voluntary patient enrolment take Australia towards UK-style capitation?

When the MBS general practice review committee released its long-awaited recommendations in December, one stood out.
 
In its report, the Medicare Benefits Schedule (MBS) expert committee recommended that patients should be able to enrol with a practice and nominate a regular GP. In return, practices and GPs would receive a payment for enrolling patients.
 
‘Patient enrolment will encourage practices to build continuity of care into their business models, ensuring support for longitudinal care and population health, as well as acute, episodic care,’ the report stated.
 
‘Enrolment will lead to stronger GP stewardship, with GPs supported to drive data-driven improvements in quality of care, and in referral and prescribing practices leading to potential downstream savings from preventable hospitalisations.’
 
This recommendation now looks like it may become a reality, with a $100 million per year program tipped for next Tuesday’s budget.
 
The Herald Sun reports the new measures would fund GP clinics to offer comprehensive care packages for chronically ill patients, as a way to reduce hospitalisations for patients who frequently visit GPs.
 
RACGP President Dr Harry Nespolon has offered initial support.
‘We would support the reported introduction of an incentive for practices to enrol patients if properly funded,’ he told newsGP.
 
‘Voluntary patient enrolment will help GPs and patients forge strong relationships, which in turn means better health outcomes for the patients GPs are responsible for.’
 
Since 2015, the RACGP has been calling for voluntary patient enrolment as a way to boost continuity of care, with the emphasis on ‘voluntary.’  
 
‘Patient enrolment must be voluntary for both the patient, and the general practice and GP (ie patients may choose whether or not to enrol, and GPs and practices may choose to participate in the program),’ the RACGP Vision for general practice and a sustainable healthcare system states.
 
If properly funded, the RACGP supports the introduction of an incentive for practices to enrol patients.

According to Dr Michael Wright, Chair of the RACGP Expert Committee – Funding and Health System Reform (REC–FHSR), the term ‘patient enrolment’ can lead observers to see parallels with the UK’s very different funding system for general practice.
 
In the UK, patients must formally register with a general practice as part of the capitation model in which clinics receive funding based on the number of patients enrolled, rather than the amount of care provided.
 
‘Capitation is where the government says, we’ll pay this practice an amount to provide all the care for this patient, no matter if they come zero or 20 times. It’s a cap on the amount of money spent. This is often linked to patient enrolment,’ Dr Wright told newsGP.
 
‘But the MBS Review recommends voluntary patient enrolment, which isn’t linked to capitation. It just means you enrol with a practice and say this is your preferred practice. But you don’t have to go to it.
 
‘Enrolment signals to the practice that this is my preferred place for healthcare. That signalling gives [GPs] the go ahead to send recalls about preventive health. We can more actively follow you up if we feel you need care.
 
‘It’s not about saying you have to go to this practice and you can’t go elsewhere.’
 
The Federal Government’s Health Care Homes trial uses voluntary patient enrolment as part of an effort to coordinate treatment of chronic and complex conditions.
 
The RACGP withdrew its initial support for the trial over concerns about a lack of adequate funding, and the use of a capitation funding model.
 
University of Technology Sydney (UTS) Distinguished Professor of Health Economics Jane Hall told newsGP she is has doubts regarding the idea that voluntary patient enrolment would bring major benefits.
 
‘I’m somewhat sceptical about the benefits that enrolment – voluntary or mandatory – may bring over and above what we have now,’ she said.
 
‘Voluntary enrolment is supposed to encourage the patient to identify with a doctor and practice, but good research shows most patients already identify with a regular practice. Not as many have a regular doctor, but a lot of that is around bigger practices and different work styles. It’s very hard to only see one doctor if they aren’t available. 
 
‘Patients already have a lot of connection with a practice and we can see that gets stronger as they get older and as they develop chronic diseases.
 
‘We see a lot of patients who manage their encounters in quite a sensible way. They have a practice they go to for more serious conditions, but they’re very happy to go to a different practice near work or in a more convenient location when [the medical issue is] acute or when one contact may be enough.’
 
Professor Hall said there is a body of evidence showing people with greater continuity of healthcare have better health outcomes and are more likely to adhere to healthcare professionals’ recommendations.
 
‘This research is correlation not causation – it could be that people who are likely to be compliant with drug-taking regimens and treatment are the people who choose better continuity of care,’ she said.
 
‘What is clear is that information is very important, and that means access to medical records by the practitioner you’re seeing. That’s achieved by people who go back to the same practice, even if they see a different GP.
 
‘But that benefit is offered by electronic medical records being available to any provider.’
 
University of New South Wales (UNSW) Scientia Professor Mark Harris told newsGP the benefit of voluntary patient enrolment lies in boosting the responsibility practices have for enrolled patients.
 
‘If you are enrolled, practices can then have systems to remind patients they need to come for a follow-up visit,’ he said. ‘It’s outreach to patients, which is very important to high-risk patients, who really need continuity of care.’
 
Professor Harris said enrolment could strengthen the GP–patient relationship.
 
‘For sensitive issues, you want to be able to talk in the context of a relationship with the patient,’ he said. ‘For obesity, drug and alcohol cessation, or mental health issues – any of those are strengthened if you have a relationship, where there’s some confidence there will be follow-up.’
 
‘If a GP doesn’t know if they’ll see the patient again, it’s very difficult to have a long-term plan for their care. That means you tend to have acute problems dealt with, and the long term ones not dealt with.’

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