What could have been a great step forward for health providers in the private and public sector, and the health consumers, to provide and access a cohesive, diverse and well funded point of contact and coordination, a future Medicare Local is unlikely to enhance any of the existing, or future, health and welfare services in the Southern Highlands. Just in the same way that the current Division of General Practice is failing to deliver the support and services expected, and required, by the general practitioners in the Southern Highlands.
What will we learn from the Medicare Locals tender documents?
Melissa Sweet
The tender documents for the first of the new primary health care organisations known as Medicare Locals are expected to be released any day now. Presumably, this is the place to keep an eye for them.
Dr Harry Hemley, president of the Australian Medical Association Victoria, has some questions about how they will work, as per his piece below.
Croakey has plenty of other questions too – including what will be their impact on the inverse care law, and population health more broadly? And will they entrench or address some of the problems associated with fee-for-service health care?
Are there better alternatives to Medicare Locals?
Dr Harry Hemley writes:
Prime Minister Gillard’s revised health proposal is an improvement on Kevin Rudd’s complicated hospital financing plan, with promises to deliver increased funds, more beds, transparency, greater clinical input and less red tape.
But the PM’s proposed expansion of Rudd’s Medicare Locals could prove a costly exercise without improving access to GPs and allied health providers in the community. So far Medicare Locals are mysterious bodies that promise to increase bureaucracy and reduce patient choice – not a wise investment if we’re striving to keep patients out of hospitals.
And given the current boundaries span hundreds of kilometres, they may not even be local.
Since the Commonwealth Government first announced Medicare Locals in April last year, health workers, consumers and even state government representatives have puzzled over their role and how they will work. And if these health care providers and bureaucrats are puzzled just imagine the need to provide clarity to the people who will be dependent upon the Medical Locals - the health consumers.
The health sector is awaiting the release of the tender documents from the Commonwealth that should make it clear what these new Medicare Locals will actually do. So far we have just been told that Medicare Locals will make things better, but not how.
We know they will provide (or maybe coordinate) after-hours care to communities and coordinate access to specialists and allied health professionals but we don’t know who will run them, whether they will offer health services, and whether they will be an improvement on current services. Socrates notes that none of these questions have been discussed with, let alone, described to, the local communities and service providers of the Southern Highlands and the Macarthur area by the respective Boards of the Divisions of General Practice.
With an initial price tag of almost half a billion dollars, this was an enormous cost for such vague objectives. We have been asked to take on Medicare Locals as an act of faith.
To justify such a cost, the Commonwealth needs to show how patient care will be improved with Medicare Locals. I’m yet to be convinced.
One of the biggest frustrations in primary care is patients’ difficulty getting an appointment to see a GP. There are no quick fixes to increase the supply of GPs – it takes around ten years for a GP to finish their training – and Medicare Locals are certainly not going to produce more GPs. In actual fact, given the primary care gatekeeper role that Medicare Locals will provide, it is conceivably possible that only those general practitioners and the Division of General Practice's "preferred" clinical practitioners will be receiving the referrals of patients from the Medicare Local.
My fear is that Medicare Locals could actually reduce patients’ ability to choose their health care provider. If a new central bureaucracy is in charge of rationing care and linking patients with providers, what is to stop them attempting to contain costs by referring the patient to the least expensive provider? Or only those practitioners who are in favor with the Division's "Medicare Local"
GPs currently coordinate the care of patients with chronic diseases such as diabetes, cancer and heart disease and the conditions that lead to these diseases like obesity. For a diabetic patient, for instance, their GP would oversee their care and coordinate the services of a diabetes nurse, a dietician, a podiatrist, and an endocrinologist. So what will change with a Medicare Local run by the Macarthur-Southern Highlands Divisions of General Practice?
There are flaws to this system but these would be fixed with minor adjustments, such as an increase in patient rebates to see their doctor, nurse or allied health practitioner, and better rebates for longer consultations. It’s not a system that requires a complete overhaul, especially when the alternative is care coordination on a bureaucratic scale. So, do we really need a Medicare Local - or would us having access (as we now do) to our preferred General Practitioner simply suffice? After all, not even the current Divisions of General Practice have the veracity and collegiate governance to inspire all general practitioners to want to join them! Will a Medicare Local be any better for the residents of the Southern Highlands? Do we even need a local Division of General Practice?
With extra funding for general practice clinics to take on additional nurses or expand their premises to accommodate extra psychologists, dieticians, other allied health providers (and even specialist doctors), patients with chronic diseases would see vast improvements.
Another cheaper and more effective way to improve the care coordination of a patient with complex medical needs is to fund care coordinators within primary care settings. This would ensure patients connected with all of the services they needed – meals on wheels, home help, their pharmacist and home nursing care – and allow their clinic-based doctors, nurses and allied health practitioners to spend more time seeing patients rather than organising services.
The PM has promised that access to after-hours medical care would improve with Medicare Locals. The plan is to establish an after-hours national call centre which can refer to a nearby after-hours clinic. This makes for a great announcement but it fails to address the problem: GPs are reluctant to open after hours because patient rebates barely cover the cost of opening, paying reception staff, hiring security guards and attracting practice nurses.
Again, some improvements to the current system would achieve better access for patients. With fair funding for general practice clinics to remain open after hours, patients would be able to visit the clinic of their choice at a time convenient to them.
Prime Minister Gillard has given herself and the states until the middle of the year (2011) to work out the details of the health deal. No level of tweaking can fix the problems with Medicare Locals. The whole concept – spending half a billion dollars to employ bureaucrats to coordinate the care of patients they’ve never seen – is flawed. The Prime Minister should consider simpler and more streamlined alternatives. It could even save millions of dollars. Given the current discussion about the severity of the proposed Budget cuts for existing programs to enable the Federal government to bring the Budget back into surplus, perhaps this is one program where the "less rather than more" principle can apply to the proposed Medicare Locals, especially here in the Southern Highlands and the Macarthur areas. Socrates would be happy to have no such Medicare Local, or even a Division of General Practice if it meant that other more worthwhile programs could continue to be funded.
• Dr Harry Hemley is president of the Australian Medical Association Victoria
