By the AGPA Web Team
Among the many sweeping recommendations of the Royal Commission into Aged Care are a couple of specific recommendations that directly affect GPs and medical practices that could be inconvenient and costly at best and harmful at worse.
The Federal Government would do well to consult more widely before adopting them.
The recommendations relate to a new model for the way that medical practices are paid and limiting prescribing capacity of GPs to people in aged care.
On payment to general practices, Recommendation 56 calls for “a new primary care model to improve access”. But the model it outlines it at odds with the way nearly all general practice businesses run and would be so financially ruinous for many that they would have to vacate the aged-care field.
Under the model general practices could apply to become accredited aged care general practices.
The practices would enrol people receiving residential care or personal care at home who choose to be enrolled with that practice.
Each practice would receive an annual capitation payment for every enrolled person, based on the person’s level of assessed need.
Each practice would agree with each enrolled person and the person’s aged care provider on how care will be provided, including by any use of telehealth services and nurse practitioners.
Each practice would be required to:
Meet the primary health care needs of each enrolled older person (including through any cooperative arrangements with other general practices to provide after-hours care if required).
Use My Health Record in conjunction with aged care providers.
Initiate and take part in regular medication management reviews.
Prepare an ‘Aged Care Plan’ (in collaboration with a geriatrician and the aged care provider and others) for each enrolled person.
Accept any person who wishes to enrol with it (subject to geography) to avoid practices accepting only patients with less complex care needs.
Report on performance against a range of performance indicators, including immunisation rates and prescribing rates.
The capitation payment would be reduced by the value of benefits paid when an enrolled person sees a general practitioner in another practice.
The accreditation process would be tightened over time.
The recommendations mirror the submissions made by counsel assisting the commission in December. At the time, they gave rise to fears that the arrangements might become so costly and burdensome with not enough return and that many GPs and practices would withdraw from providing aged-care services. Those fears must now be greater.
The capitation model indicates that the commissioners had little understanding of general practice business models. The GPs who work in them are contractors, not employees. Courts have agreed that this is the case largely because the GPs operate independently and have a direct relationship with the patient. The patients get the Medicare benefit which gets paid to the GP, not to the practice as a whole.
With capitation, however, the contractual relationship would be between the practice as a whole and the government and the practice would be paid directly. That would mean the courts might recategorise the GPs as employees, not contractors. If that happened the practices would become liable for state payroll tax and superannuation and leave. Those burdens would make capitation arrangements unacceptable for most practices.
Added to that, the commission’s final report did not say how the capitation would be calculated, who would calculate it, or whether it would be in place of or in addition to Medicare payments.
No process of review or indexation was mentioned. This can be particularly important as health-care costs have been rising far higher than inflation.
Moreover, given the history of governments slowly contracting payments to general practitioners and general practice, many would be wary of entering this system without a great deal more detail.
Interestingly, the two commissioners have differed in significant ways about the best way to improve aged care. In broad terms, Lynelle Briggs, a former Public Service Commissioner, wants it run from the Department of Health whereas former Federal Court Judge, Tony Pagone QC, wanted an independent commission running it.
And there were significant differences in each one’s approach to funding.
Commissioner Pagone wanted capitation to be run as a trial. Commissioner Briggs wanted it set up immediately.
So, it is not as if Royal Commissions are the fount of all wisdom, even if they run for two years and cost $92 million.
In any event, the capitation system proposed will not work for most practices. And as aged care is difficult for single-doctor practices because of its 24/7 nature, it is difficult to see this major recommendation of the Royal Commission being implemented without major changes.
On prescriptions, Recommendation 65 says: “By 1 November 2021 , the Australian Government should amend the Pharmaceutical Benefits Scheme Schedule so that:
“a. only a psychiatrist or a geriatrician can initially prescribe antipsychotics as a pharmaceutical benefit for people receiving residential aged care, and
“b. for those people who have received such an initial prescription from a psychiatrist or a geriatrician, general practitioners can issue repeat prescriptions of antipsychotics as a pharmaceutical benefit for up to a year after the date of the initial prescription.”
There are obvious flaws to this recommendation. First, it is to come into force in just nine months. That does not leave much time for consultation and exploration of unintended consequences.
Secondly, restricting initial prescription, which would include varying a prescription, to two just kinds of specialists will inevitably mean patients would have to wait longer for treatment. Not all aged care facilities get daily or even weekly visits from these kinds of specialists. In short, patients will be denied prompt primary care, especially patients in remote or smaller communities.
Dr Max Kamien, Emeritus Professor of General Practice at the University of Western Australia, has written that, if the commissioners had spent a week as a carer in a dementia ward, “They would have learned that it is not easy to attract GPs to work in nursing homes and that those who do so do it out of altruism rather than job satisfaction or income enhancement.
“They would also have learned that GPs are not idiots, that they know the context of the patient’s problem and care and they are far, far more available than the specialists who charge 6-10 times as much for the same task but without the benefit of context or continuity.”