Economics undermine after hours lure medical observer

Economics undermine after-hours lure - Medical Observer

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Economics undermine after-hours lure 5th Jun 2015 Julie Lambert all articles by this author

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CONTROL of after-hours primary care is being returned to GPs in a back-tothe-future move that practice principals are advised to study carefully.

The after-hours Practice Incentives Programme being adopted on 1 July offers a top payment for round-the-clock coverage that’s more than five times the miserly $2 flat rate (per weighted average patient) under the PIP system scrapped in 2013.

Dr Paul Mara, a GP in Gundagai, NSW, says the more generous scheme will help build up the rural workforce, coming on top of other targeted incentives.

“For practices in the bush providing full-time care, the amount of money has gone up considerably. There is a considerable number of practices providing that kind of care,” he says.

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“What that money will do is provide capacity, so individual doctors are not necessarily working 24 hours a day, seven days a week."

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Practices providing round-the-clock care can apply for a Tier 5 PIP of $11 based on the Standardised Whole Patient Equivalent (SWPE) or “swappie”.

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Practice management consultant David Dahm says rural GP proceduralists, larger practices where little or no after-hours service exists and practices in remote areas will easily qualify for the top payment.

Importantly, the new after-hours regime allows more flexibility by including GP telephone advice and telehealth services, as well as home visits and inpractice consultations.

But Dr Mara, a member of the expert panel that advised the government on rural GP incentives, says it’s incorrect to suppose GPs will cover more and more services after hours and patients won’t need hospital care.

“My experience of 33 years doing after-hours virtually day in day out is that patients will present with primary care-type things up until 7–9pm.

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"After that, patients often need a higher level of acuity of management and treatment and observation.

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“For remote and rural areas, what you need is to solve the workforce, get the right doctors with the right skills, and provide the right services – continuity of care is one of those services. You don’t need funny solutions.

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"I suspect the visiting medical officer model is highly cost-effective and needs to be supported, and the best thing the government could do is incentivise practices to stay open another couple of hours.”

The government has committed more than $410 million over four years to the scheme, aiming to expand after-hours primary care and avoid unnecessary hospital visits.

"Certainly the intent of the program is to incentivise more after-hours by general practice,” Mark Booth, the health department’s first assistant secretary for primary care, said in Senate estimates this week.

“That is why the $11 weighting is strongly around the individual practices doing more. So we would expect to see an increase in the number of practices that are providing after-hours support.”

Mr Dahm says larger practices, with seven or more GPs, may find it more viable and practical to apply for Tier 3 or Tier 4, each paying $5.50 per SWPE. Based on an average practice load of 900 SWPE per full-time-equivalent GP,

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Economics undermine after-hours lure - Medical Observer

a seven-doctor practice could reap after-hours incentive payments of some $50,000 a year, he says.

“The key is good patient demand systems, a well-organised practice manager and a rostering system where you can draw on a pool of at least 14 doctors,” he told MO. But having set up and run after-hours clinics in public hospitals and private practices, Mr Dahm says most won’t make money after 10pm. He calls the 11pm requirement “onerous”.

“The economic fundamentals undermine a well-intended principle,” he says.

Dr Mara agrees: “If the government makes it worthwhile for practices to stay open till 8 or 9 o’ clock in metro areas, they would solve 90% of their problems."

Tier 4 will apply where practices cooperate to provide care for the complete after-hours period (outside 8am–6pm weeknights and 8am–12pm Saturdays).

Tier 3 covers direct care of practice patients during the “sociable after-hours” period of 6pm–11pm weeknights, with formal arrangements for a substitute service in place for other times.

Under Tier 2, practices can attract $4 per SWPE by cooperating to cover the sociable after-hours period (6pm–11pm weeknights) and making arrangements for patients at other times.

A shared after-hours roster may appeal to urban practices wanting to stop patients drifting off to large corporate outfits for the sake of convenience, but they should beware the administration burden, Mr Dahm says.

In reality, growing demand for after-hours primary care has been led by nonurgent consultations on practice premises on weeknights, mostly in urban areas in the country’s east and southeast.

This was the main factor driving the increase in after-hours MBS claims over the four-year period to 2013, according to the report into after-hours primary care by former RACGP president Professor Claire Jackson.

Another conspicuous driver of growth was in services by medical deputising services, in many cases backed by Medicare Locals.

As for Tier 1, any practice can pocket quarterly payments of $1 per SWPE simply for having a phone arrangement with a locum service.

“My argument would be to get rid of category one and give the money to people who are actually trying to run an after-hours service and save some money on the budget,” Mr Dahm says.

Tags: Paul Mara, Mark Booth, PIP, after hours, David Dahm, visiting medical officer, Medicare, Medicare Locals, Practice Management, Rural Workforce, Professional News Share:

http://www.medicalobserver.com.au/news/economics-undermine-afterhours-lure[23/06/2015 10:09:24 AM]