Cost ver­sus care di­vides doc­tors

Fixed bud­gets are the lat­est health hot potato. Health edi­tor Adam Cress­well ex­am­ines the ar­gu­ments on either side

The Weekend Australian - Travel - - Health -

FOR a cou­ple of years now, Mel­bourne GP Michael Nolan has been in­volved in a scheme that al­lows pa­tients with men­tal health prob­lems to be re­ferred to a psy­chol­o­gist. True, there’s noth­ing par­tic­u­larly star­tling about that, since var­i­ous Medi­care re­forms in­tro­duced in the past few years have in­cluded this sort of pro­vi­sion. But in many cases, pa­tients re­ferred through these Medi­care mech­a­nisms are left with a sig­nif­i­cant out-of-pocket cost — the dif­fer­ence be­tween the re­bate Medi­care will pay, and what the psy­chol­o­gist ac­tu­ally charges.

Un­der the Ac­cess to Al­lied Psy­cho­log­i­cal Ser­vices pro­gram (AT­APS), the pa­tient pays no upfront fee at all — some­thing Nolan says is the only way to make these ser­vices ac­ces­si­ble to less-well-off pa­tients.

‘‘ These pa­tients re­ally love it, be­cause it means they can get these ser­vices which would oth­er­wise be out of their reach,’’ he says. ‘‘ Pa­tients on health care cards (con­ces­sion cards) of­ten have high rates of psy­cho­log­i­cal ill­nesses. They think it’s fan­tas­tic, be­cause they can get fairly quick ac­cess to ser­vices.’’

If the scheme didn’t ex­ist, pa­tients who could not af­ford the typ­i­cal $50 to $100 gap pay­ment to see a psy­chol­o­gist would face a wait of be­tween six to 12 months in the pub­lic sys­tem.

‘‘ A lot of peo­ple just months,’’ Nolan says.

But while AT­APS might be fan­tas­tic from a pa­tient’s point of view, it and sim­i­lar schemes are prov­ing con­tro­ver­sial from the view­point of oth­ers.

The Aus­tralian Gen­eral Prac­tice Net­work, the na­tional um­brella body for lo­cally-based ‘‘ di­vi­sions’’ of GPs, says the pro­gram is an ex­am­ple of ‘‘ block-funded’’ schemes, which are shap­ing up as a point of con­tention within the med­i­cal pro­fes­sion.

The AGPN has pro­posed sev­eral schemes to tackle a va­ri­ety of health prob­lems, in­clud­ing di­a­betes and over­weight and obe­sity — most re­cently in its pre-bud­get sub­mis­sion to the fed­eral Gov­ern­ment, re­leased this week.

This has not gone un­no­ticed by the Aus­tralian Med­i­cal As­so­ci­a­tion, which has long op­posed block-fund­ing schemes and in De­cem­ber warned that they ‘‘ work against qual­ity health care’’.

As­so­ci­a­tion pres­i­dent and Perth GP Rosanna Capolin­gua said at that time that with ‘‘ capped bud­gets’’, doc­tors ‘‘ would face pres­sures to min­imise ex­pen­di­ture on ser­vices be­cause when the money runs out, the ser­vice runs out’’. ‘‘ That means that they can­not



nine care for their pa­tients in the way that is needed,’’ she said.

The AMA of­ten uses the term ‘‘ fund­hold­ing’’, know­ing full well that for many doc­tors this word is like a red rag to a bull — mainly be­cause it re­calls the pri­mary care re­forms in­tro­duced in the UK by Mar­garet Thatcher.

The Thatcher re­forms al­lowed GPs to cut their fund­ing ties to Bri­tain’s Na­tional Health Ser­vice, and in­stead opt to be­come ‘‘ fund­hold­ers’’. In this case, they were al­lo­cated a pot of money, cal­cu­lated on the size of their pa­tient pop­u­la­tion (pa­tients have to be regis­tered with named GPs in the UK) and the ex­pected pat­terns of ill­ness in that area.

The money would then be used to pay for the med­i­cal treat­ment needed by the pa­tients regis­tered with that GP.

The idea was that it would con­tain costs, be­cause the sys­tem cre­ated an in­cen­tive for GPs to avoid un­nec­es­sary re­fer­rals and other ex­pen­di­ture. But the pro­gram soon hit con­tro­versy when some GPs found them­selves run­ning out of money be­fore the year had ended, mean­ing some pa­tients could not get the treat­ment they needed.

Sub­se­quent re­forms fo­cused in­stead on al­lo­cat­ing the fund­ing pools across en­tire re­gions rather than in­di­vid­ual doc­tors — mak­ing it much less likely that the money would run dry if by chance there were a few more cases than in an av­er­age year re­quir­ing ex­pen­sive treat­ment, such as coro­nary bypass surgery.

In Aus­tralia, any pro­gram akin to fund­hold­ing gets flak from the AMA partly be­cause of this con­cern that it is prone to lead to ra­tioning as the pool runs low. The AMA also says fund­hold­ing is in­her­ently bu­reau­cratic, and op­poses any pro­gram that re­places Medi­care and the con­comi­tant right of all pa­tients to see their doc­tor when they need to, and to re­ceive a Medi­care re­bate for that con­sul­ta­tion.

In the Aus­tralian con­text, there is no pro­posal to in­tro­duce fund­hold­ing across all pa­tient groups, either in par­tic­u­lar ge­o­graphic ar­eas or na­tion­wide.

But there are al­ready ex­am­ples of pro­grams that share some of the char­ac­ter­is­tics of fund­hold­ing, op­er­at­ing both in spe­cific lo­cal ar­eas and for spe­cific pa­tient groups.

AT­APS, aimed par­tic­u­larly at young peo­ple and dis­ad­van­taged adults, is one such ex­am­ple. Set up by the for­mer Howard Gov­ern­ment, it pays funds to par­tic­i­pat­ing di­vi­sions of gen­eral prac­tice, which ad­min­is­ter the pot of money in their area.

As Nolan ex­plains, when a pa­tient comes through the surgery door, the GP can make an as­sess­ment of the pa­tient’s el­i­gi­bil­ity for the pro­gram, and if suit­able can phone or mes­sage the di­vi­sion’s head of­fice to ask for the new pa­tient to be in­cluded.

Vouch­ers held by the di­vi­sion, which en­ti­tle the pa­tient to see any psy­chol­o­gist on a pre-ap­proved list, are for­warded to the GP when the new pa­tient is ac­cepted.

Af­ter the GP has con­ducted an as­sess­ment and com­pleted a men­tal health plan, they can re­fer the pa­tient to a psy­chol­o­gist. The pa­tient is given the vouch­ers, and gives these to the psy­chol­o­gist in place of pay­ment. The psy­chol­o­gist then bills the di­vi­sion, which pays us­ing the funds given un­der the pro­gram.

‘‘ There’s no doubt that there’s an is­sue with red tape, but that be­dev­ils the Medi­care fee-for-ser­vice sys­tem too,’’ says Nolan, who

‘ is both a mem­ber of the AMA and his lo­cal di­vi­sion, which he chairs. ‘‘ It’s true some of the pa­per­work is quite oner­ous. But I don’t think it cuts across clin­i­cal in­de­pen­dence — the ben­e­fits for the pa­tient are ev­i­dent and GPs are still in con­trol of the process.’’

In the early to mid-1990s Aus­tralia tri­alled a mod­i­fied ver­sion of fund­hold­ing at var­i­ous

Pic­ture: David Ger­aghty

Sup­porter: Doc­tor Michael Nolan uses the AT­APS pro­gram, say­ing his needy pa­tients think the scheme is fan­tas­tic’

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