Arn Sprogis* agrees that general practice is the key to improved quality of care, but ponders what mix of public and private structures will best support it.
Ineffective policy making by successive federal governments has pushed the Australian health system into the first stages of a disruption that could be even greater than the impact of Medibank over 30 years ago.
This disruption is being driven by the need to resolve the three major health care and health financing challenges:
how to best manage chronic and complex care, and by whom?
how to best manage avoidable hospital admissions/care, and by whom?
how to finally get equity in access to care, particularly for rural and regional populations?
The many keen observers of our health system see clear signs of major change. We have an absent commonwealth government , private health insurers (PHIs) moving into general practice, corporate GP practice rapidly increasing, and an impending flood of new medical graduates.
Add to this mix another restructure of the primary care system, with Medicare Locals (MLs) soon to become Primary Health Networks (PHNs).
How this fits together will shape not only general practice but secondary and tertiary care, particularly hospital care. However, there are enormous opportunities for rural and regional GPs.
The key factors that will shape this change will be the effect of the Commonwealth government’s shifting its health system responsibilities back to the states and the various jurisdictions’ approaches to how general practice fits within a reshaped health system able to deal with the ‘three great challenges’.
Today, there is a welcome increase in longevity and an unwelcome increase in chronic and complex conditions. Improving the quality of hospital care, or reducing hospitalisations, cannot be done without the central involvement of general practice.
Having finally seen the critical nature of this relationship, PHIs are acting rapidly and decisively. Nowhere is this more obvious than in the discussions around what a PHI’s relationship might be with a PHN. A more radical view would be that where Medicare after 30+ years has failed to deliver equity of access and financing for rural and regional populations, PHIs taking responsibility for these populations may achieve greater gains.
If PHIs were to be given greater responsibility for financing healthcare for rural/regional populations then my view is that individual PHIs won’t do it by tendering for PHN contracts. The reasons are simple.
First, the idea that an individual PHI could have a monopoly position in a defined region without deeply compromising the existing competitive arrangements with other PHIs operating in the same region makes it untenable, at least to the other PHIs.
More importantly, regional communities would quite rightly be deeply suspicious of a national corporate deciding regional resource allocations and directions in healthcare when they have no regional track record at a population level. Communities would prefer their own community members and clinicians to take leadership of the PHN.
Lastly, PHIs have little or no experience or capacity in dealing with general practice in all its complexity, although with the demise of MLs in 2015 a large number of staff with capacity and expertise will be released into the job market.
However, PHIs do have the organisational capacity to focus on the hospital avoidance and interrelated chronic and complex disease task, and act on it in real time, and over long time frames. This could deliver quality outcomes in less than the geological timeframes of government.
If PHIs and PHNs insisted on funding being equitable in rural and regional communities then for the first time in any GP’s living memory their communities would achieve health care equity, and major investment in health care would be possible.
PHIs and PHNs working together would not be paralysed by electoral imperatives, populism or the need to be elected.
The mechanisms by which PHIs can act to achieve system disruption has two likely scenarios, which revolve around whether there is or isn’t a relationship between PHIs and PHNs. This will depend on the level of responsibility and scope of activity given to PHNs by the government.
In one scenario, PHIs will bid for the opportunity to be preferred providers to PHNs in delivering integrated care. They would rapidly try and tie up contract arrangements with PHNs to support integrated care for their customers through individual general practices (or their corporate equivalents).
The alternative scenario is that PHNs are not given any responsibility of consequence “to integrate the care of patients”. If so, PHIs will take action to ignore PHNs and deal directly with general practice, focusing on reduction of hospital admissions, reductions in variability of specialist care, and improvements in quality care.
Either way, this has the potential to lead to innovation and acceleration of the quality care movement in general practice and initiatives like the Patient Centred Medical Home may be rapidly advanced as a preferred option.
So, precisely because we have what appears to be a policy vacuum, or at least policy silence, we may finish up with changes to primary care health systems which once started will lead to a very different health system and a radically changed experience for our communities.
Whichever way things go for PHNs, PHIs will play a key role in the process in major cities, although it is unclear what the possible consequences might be in rural and regional areas. What is clear is that general practice is the key to success in improved quality of care.
In simple terms, the dominance of secondary and tertiary care systems has peaked and that of Primary Care is on a rapid rise. The only question will be what organisations will take on the challenge and therefore be the disruptors of the current system. It is likely the most focused organisations with the clearest objectives will dominate, and PHIs and PHNs are the most likely to take on that role.
It lies with rural and regional GPs to seize the opportunity that a major disruption will provide to improve the health care financing and provision for their communities.
*Dr. Arn Sprogis is Chairman, Australian Medicare Local Alliance