Representatives from the peak GP bodies have dismissed the Counsel Assisting’s proposition that general practices should be paid ‘performance payments’ based on factors such as immunisation rates or diabetes management planning, saying unlike other areas of the health system, residential care has no scope for outcomes-based payments.
Taking a similar tack to the previous panel, the Senior Counsel questioned Dr Anthony Bartone (pictured above), the President of the Australian Medical Association (AMA); and Associate Professor Mark Morgan (pictured below), the Chair of the Quality Care Committee at the Royal Australasian College of General Practitioners since October 2018, over 80 minutes on a range of propositions around health care and aged care, including:
That the funding model needs to be reformed to provide a blended payment to cover the delivery of health care services into residential care:
Like the GPs earlier, Dr Bartone argued there is a need to review the funding to compensate GPs for the work they do that is not covered under the MPS.
“Certainly there is a significant amount of work being done at the moment in the primary care steering group by the Minister that is looking at a voluntary nomination payment for those – at this stage for those over 70 in the community that nominate a GP or a GP practice as their usual doctor,” he said. “That kind of backbone could be – that kind of funding arrangement could be the backbone if appropriately funded to ensure that there was both that blended component but also a significant redress of that MBS item funding.”
However, the AMA President said there was no scope at this stage for any kind of outcomes-based payment – where GPs are paid to improve residents’ health – in aged care.
Assoc Prof Morgan was also against a pay for performance or strict outcome-based pay, saying it distorts clinical decision-making and – clearly borrowing from the other GPs – leads to a number of unintended consequences.
“The College is supportive of schemes that encourage quality improvement,” he stated. “So that’s a – a subtle difference from outcomes-based pay. It’s about improving from where the situation is now and becoming a learning organisation to move on and get better, rather than reaching some threshold to achieve some payment.”
That there should be blended payment arrangements under which GPs servicing aged care residents would receive an annual payment based on the health needs of the resident or group of residents blended with fee for service payments for complex or after-hour attendances and performance payments based on factors such as immunisation rates or diabetes management planning:
Given the comment above, no surprise that Assoc Prof Morgan disagreed with the idea of a performance payment.
“In residential aged care patients tend to be more complex with more medical conditions, complex polypharmacy, some patients will be moving towards a palliative care approach and so it’s really hard to conceive of any sensible measures of – that would support a pure outcomes-based payment,” he argued. “There is another way of providing some almost block funding by enhancing the value or – and content of things like comprehensive medical assessments so that they provide in some ways a fee for a comprehensive and detailed service including some forward care planning and care coordination.”
That the MBS items related to comprehensive health assessment should be amended to allow for assessments in residential care and home care every six months:
Naturally, Dr Bartone has no objection to this idea, saying the increasing complexity of care needs in aged care lends itself to more frequent assessment.
“We need to take a really long-term approach but we do need to look at ensuring that continuity of care which underpins good clinical care is fostered,” he said.
That nurse practitioners play a part in caring for aged care residents as part of a multi-disciplinary team; be able to make comprehensive health assessments and have access to similar MBS items as GPs:
On the other hand, Dr Bartone had little support for the idea of nurse practitioners taking on a greater role in caring for residents.
“The nurse practitioner model has a defined scope of practice, usually under supervision or delegation with a supervising medical practitioner. They work really well in acute clinical environments such as emergency departments or hospital departments where there are an abundance of other medical specialists professional present,” he stated.
“Having independent access to the MBS is only going to fragment care and increase duplication and increase unintended outcomes,” he added. “Working collaboratively as part of the one team therefore then we can really increase both the outcomes, both the care and both the immediacy of treatment provided.”
That hospital-led outreach services i.e. flying squads into residential care be expanded nationally with dedicated funding from the States and Territories and the Commonwealth:
Assoc Prof Morgan agreed they should be rolled out, but had a few caveats – namely, that they don’t replace GPs.
“There’s a concern over the patchy availability of flying squads or reach out services but also they need to work closely and not set up a parallel version of care from general practice care because it’s the GPs that will be visiting on a regular basis providing follow-up care and adjustments to following the crisis intervention,” he said.
“I think it needs to be really recognised that the week by week care of residents is going to fall to primary care. There’s no way to consider scaling up outreach services to provide that level of care.”
Dr Bartone added that any service would need to be patient-centred and funded systemically by both the States and Territories and the Commonwealth.
That there should be better financial incentives to encourage specialists such as geriatricians, psycho-geriatricians, palliative care specialists, rehabilitation specialists to provide a minimum level of services into residential aged care:
Assoc Prof Morgan agreed there was a place for funding specialists to provide an increased level of service, while Dr Bartone suggested the MBS items numbers for specialist services could also need to be expanded to support this idea.
It was clear Commissioner Lynelle Briggs (pictured below) felt passionately about this issue.
“The sad reflection on this is that people in residential aged care have lower access to specialists, more generally, than anyone else in the community,” she remarked. “And this is a shocking state of affairs. And it seems the only way they can access specialist services is to be hospitalised. Has either of your organisations – I suppose I should look directly at you, Dr Bartone, from the AMA side because you cover specialists; have you been thinking about what might specifically encourage specialists to act in this field or do we take it as a fait accompli that they aren’t going to visit residential aged care facilities, so the people concerned either need to go to a hospital or they need to have transport that takes them to specialist offices to get the kind of investigatory and preventative care that other members of the community are entitled to?”
Dr Bartone agreed there is scope for ‘outpatient clinics’ in some aged care facilities, but noted many hospitals are now quite distanced from primary care teams and they would need to work more cooperatively to provide services at the point of care of the resident.
“Is there anything that would force that to occur; and I mean significantly incentivise it to occur?” the Commissioner followed up.
“The problem is, of course, that we have a federal and a State funder, so funding different sides of the equation,” Dr Bartone replied. “COAG and the COAG health processes through the Health Ministers’ forum there is certainly a forum whereby all the people are around the table and it could be made to be a significant point of responsibility in addressing this area because it is about increasing patient care, patient outcomes and efficiency of scarce health resources.”
That given the “degree of disinterestedness” of GPs in visiting aged care facilities, care coordinators should be put in place to assist residents to access services:
Perhaps not unforeseen, the AMA President took offence to this statement by the Senior Counsel.
“The disinterest as you refer to is about the frustration, the lack of clinical satisfaction, the lack of due processes being available and being followed in terms of the care that’s required to be 15 expended or enveloped around that patient,” he said defensively. “It’s about the – that everything takes a lot longer, takes a lot more effort and a lot more opportunities for things to go through the, you know, to go through to the keeper because unless you double down, triple down and ensure that you’ve exerted even more than what you would normally do, there is a, you know, there’s something might have been overlooked, you need to – everything from communication at the moment to the – the record-keeping to the – having to print out additional scripts in that process, and then the recording of the IT incompatibility at the facility with your IT at the surgery, with the fact that you’ve only just left the facility and you get a phone call to go back. They’re the things that are frustrating and concerning and problematic in terms of ensuring that your expectations of the quality of care that you want to impart for your patient, for your resident that’s in there, is why more and more doctors are deciding that no, this – I have a surgery full of patients that also require my attention.”
Assoc Prof Morgan backed Dr Bartone up, saying statistics show that 81% of residents are only billed for one item under the MBS.
“It’s a fragile situation and it wouldn’t take a lot to collapse it,” he pointed out. “So, I think we need to be very careful not to create disincentives as part of any change process.”
The Professor was also not keen on a care coordinator.
“It seems like a good idea but the reality is often not as good as the idea appeared unless the care coordinators are deeply embedded either as part of the residential aged care facility or as a role of the primary health care,” he commented. “I think if you had a third organisation that was kind of put into that mix, it would be very easy for it to be a failed experiment.”
Dr Bartone also pointed to the ageing GP workforce – which again caught Commissioner Briggs’ attention.
“There’s a real issue about the capability and the size of the medical workforce that supports these groups,” she noted, “and some of the suggestions we’ve had is that in medical training programs, young people should – young doctor trainees should have placements in aged care. I don’t know whether that would work to increase the interest, but there’s the broader question of whether or not younger doctors with the experience they have, have the capabilities to deal with this kind of complexity of care need.”
Both doctors said there is an opportunity for training young doctors in residential care facilities – and this could be taken further with an apprenticeship model.
“I think there’s – there is no limit to how much we could do,” Assoc Prof Morgan said. “It’s a case of building the right – priorities because GPs look after 500 conditions reasonably frequently and so there’s a need to – for the GPs to prioritise their own professional learning. As a profession, GPs tend to work out what their learning needs are and then seek out ways to address those learning needs. So, they’re available. I think the idea of an apprenticeship model encouraging GP registrars to latch on and work with a GP that visits residential aged care facility, I think that’s something that could be enhanced and made a very usual part of GP training.”
The Commissioner wanted more guidance however.
“Perhaps the College and, indeed, the AMA might consider coming back to us to address this – the issues to address these needs specifically because fundamentally we are dealing with a much more complex health issue for elderly people than we have experienced before, because frankly they used to die earlier,” she said. “I think that’s fundamentally what’s going on here. So, the management of these complex conditions affects the health system, it affects the aged care system and it affects the community more generally with the downstream impacts on families who witness these concerns with considerable concern and in some cases frustration or horror that they can’t seem to get the supports that people need. So, we would welcome you coming back with further submissions in this regard.”
With promises to deliver on this, the witnesses were excused.
