AMA Speech - AMA President Dr Steve Hambleton, International Primary Health Care Reform Conference
SPEECH TO INTERNATIONAL PRIMARY HEALTH CARE REFORM CONFERENCE
19 MARCH 2014
AMA PRESIDENT DR STEVE HAMBLETON
**Check Against Delivery
Driving Quality Primary Care
I acknowledge the traditional owners of the land on which we meet today, and pay my respects to their elders, both past and present.
There were once about 20,000 Aboriginal people living around here before European settlement. Their numbers dropped to about 2,000.
They were decimated by the loss of food resources and simple things like colds and flu, measles, and smallpox, for which they had no immunity. Alcohol also took its toll.
These are all primary health care issues, so it’s entirely relevant to recall that history as we speak today about quality primary health care - a subject at the core of AMA policy and advocacy.
It is clear that primary care is also a priority for the still relatively new Federal Government, and it is critically important if we want to control costs in the health system.
In tough economic times – and we know that the May Budget will be tough – the key is focusing health policy and health dollars on what works the best.
It is all about a better and smarter spend of health funding.
Governments can sometimes be more interested in reducing costs in the short term than improving health outcomes in the long term.
General practice-based primary health care is not what is driving the increase in health expenditure.
In fact, increased spending in general practice might be exactly what is needed.
The challenge is making every dollar count.
We need to reshape current systems to meet the challenge being thrown up by the major cost drivers of an ageing population with chronic and complex health needs, and the sheer volume of services capable of being delivered to those suffering the impacts of non-communicable diseases.
For example – the mortality from heart attacks in this country has decreased, so many more Australians are now living with coronary heart disease and the disability that follows an attack.
It would be far cheaper if we could prevent people developing such disease in the first place.
In Australia, many things are currently being reviewed by Health Minister Dutton which may have an impact.
There is a review of Medicare Locals that should be focused on population health in the non-hospital space.
There is a review of the Personally Controlled Electronic Health Record – which could provide a communication tool and the ability to provide audit and feedback.
There is forensic examination in the Parliament of the GP Super Clinics program – a program that was questioned by the AMA from day one.
There are other suggestions that we are not so happy about.
The Minister has said he will look at proposals for pharmacists to perform some tasks currently undertaken by GPs – outside of a team-based approach.
There was the recent leak of a policy proposal from the Pharmacy Guild to the Minister for pharmacists to provide health checks for people at $50 a pop.
Some governments are trialling vaccination by pharmacists.
Some governments allow vaccination by nurse practitioners in pharmacies.
There has been lots of discussion about GP co-payments and means testing for GP bulk billing, which may have more perverse than beneficial outcomes.
The Minister is now talking about block payments to GPs for the very small percentage of the population that are responsible for the greatest proportion of health care costs.
Private health insurers in this country are also very interested in the conversation.
This Session raises the question: Using incentives to drive quality primary care – is it all about money?
Well, a lot of the proposals that the Minister has before him provide some incentives – but some of them are to providers other than GPs.
Many of them are about money – saving money, but not necessarily about a more efficient use of money.
The AMA is strongly of the view that general practitioners are the foundation of quality primary health care in this country. A key feature of our success in primary care outcomes is the central role of the GP.
Most of the community shares this view. When people are ill or injured or want reliable health advice, they want to see a doctor.
GPs are highly trained to look after the whole body. GPs are the key to continuity of care throughout life.
The health system works best and is most efficient when all the health providers stick to doing what they do best – the jobs they trained for, coordinated by GPs to avoid fragmentation of health care, which would ultimately cost the health system more.
So, what does the AMA think we should do?
The AMA believes that Fee for Service should remain as the cornerstone funding source for general practice.
The AMA wants to see further investment in general practice through greater support for longer consultations, where more problems can be covered and preventive health issues attended to.
The AMA supports more effective funding for chronic disease management.
The AMA supports appropriate mechanisms for quality improvement.
The AMA is prepared to look at blended payment models where fee for service does not work, or as an adjunct to fee for service.
The AMA is wary of financial incentives provided to health care professionals to change their behaviour that do not appear to improve patient outcomes.
For example, where clinical indicators are used for the purposes of pay for performance, there is an inherent danger that a focus on achieving clinical indicators and performance against them diverts attention from patient care.
This danger is particularly present if outcomes measured against clinical indicators are used to dictate or impose levels of safety or quality, or for pay for performance purposes.
Cochrane reviews of a range of schemes in a range of countries that use financial incentives to reward performance and quality have determined there is little rigorous evidence of their success in improving the quality of primary health care.
Nor is there much evidence to determine if pay for performance is cost-effective relative to other ways to improve the quality of care.
A Cochrane review of the effect of financial incentives on doctor behaviour did find a significant change in behaviour in response to pay for performance.
Authors of one review found that pay for performance programs were effective in improving process measures, referrals and admissions and prescribing costs, but less effective in other areas such as adherence to guidelines or consultation rates and patient outcomes.
In the first year after the introduction of the Quality Outcomes Framework in the UK, GPs exceeded expectations - achieving 91 per cent compliance with clinical guidelines, up from around 60-80 per cent.
However, this improvement was temporary. In subsequent years, fewer quality improvement gains were made.
This may have been because the processes for meeting benchmarks were already in place.
It may have been because the incentive to improve was removed once maximal incentive payments had been received.
In some pay for performance schemes, only the top performers get paid.
There is no reward for those who may have worked hard to make improvements but haven’t hit the required benchmark – but have probably improved health outcomes substantially.
When there is little hope of reaching the mark, or the costs involved are not more than compensated for by the reward, the power of the incentive wanes.
The particular characteristics of health care settings and individuals are likely to influence the effectiveness of financial incentives and disincentives.
Our own form of blended payments is the Practice Incentives Program – the PIP - which rewards practices and GPs via Service Incentive Payments that provide practices with additional financial support to encourage and support GPs in the provision of quality care.
The AMA believes that this funding is only an adjunct to existing GP fee for service funding, and should remain so.
There is no ongoing certainty with incentives under the PIP in Australia.
They are reviewed and modified on an ongoing basis, perhaps to enhance practice capacities in the pursuit of quality, but more often than not as a cost saving measure come Budget time.
Some examples of this include:
· the diminution and cessation of the General Practice Immunisation Incentive;
· removal of the Service Incentive Payment for providing immunisation services in the 2008-09 Budget for projected savings $83.7 million over four years;
· cessation of GP Immunisation Incentive outcomes payments in the 2012-13 Budget (for having 90 per cent of children under 7 fully immunised) for projected savings $21 million per annum; and
· increasing the required targets for cervical screening and diabetes incentives purely to save money.
These cuts were all about saving dollars, not saving lives. This is not the sort of policy that improves quality primary care.
Performance payments such as PIP should pay for evidenced processes but not clinical outcomes due to difficulties in controlling and measuring.
The risks associated with pay for performance models cannot be ignored and must be considered in the design of any pay for performance model.
Some of the potential risks include:
· an enhanced focus on only those activities being measured;
· up-diagnosis of borderline patients to improve outcomes;
· cherry picking healthier patients over the more complex to more easily reached performance benchmarks;
· excluding certain patients from data collections to improve overall performance figures;
· increased red tape to report on benchmarked measures;
· the costs of participation outweighing the benefit;
· the use of inappropriate indicators such as outcome measures that are outside the practitioners’ control; and
· questionable validity of quality measures.
The AMA recognises that there are some strengths of pay for performance, such as:
· they can be a useful adjunct to encourage and reward activity aimed at improving quality care;
· pilot studies show modest improvements in specific outcomes and efficiency; and
· enabling data collection on GP activities
The AMA believes that quality care could be better encouraged if GPs were better supported to spend more time with their patients and better use the clinical teams that are beginning to build around them.
The imbalance in existing patient rebates for GP services rewards high throughput and discourages longer consultations and team-based care.
We must ensure that the design of the pay for performance program encourages quality care and minimises unintended consequences.
To minimise perverse outcomes the AMA recommends that any pay for performance program must:
· be in addition to fee for service;
· be transparent,
· provided adequate funding to support implementation of quality measures;
· align with clinical practice;
· be indexed so that payments retain their incentive value;
· measure what is appropriate, clinically relevant, and within the provider’s control;
· encourage appropriate clinical care;
· encourage preventative health care services and measures;
· encourage improvements in the quality of health care and reduce inefficient practices; and
· minimise the administrative burden on providers.
These measures would improve quality primary health care and they would allow a focus on the things we know that work and work well.
And it is not all about money. It is all about the right care at the right time in the right place by the right practitioner – the GP.
For its part, the medical profession has two areas on which to focus: first, changing the way we provide health care, where we provide it and when we provide it for non-communicable diseases; and, second, identifying cost-effective services.
Both of these will result in wiser spending.
In terms of our clinical practice, we must have a structured process for translating what we know into what we do.
This requires much greater scrutiny of what we are doing, through participating in more research into and review of our own practice, so we avoid practices that don’t provide real outcomes for patients.
Measurement and feedback is an incredibly powerful way of modifying clinical behaviour.
It can have the additional benefit of proving the worth of investment into primary care to increase our slice of the health funding pie.
The challenge for the medical profession is to accept that we do have a role in the stewardship of the health system.
Otherwise, government will step in, and health care will be dictated by health financing experiments, rather than evidence-based and effective health care delivering measurable outcomes.
19 March 2014
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