Cost versus care divides doctors
Fixed budgets are the latest health hot potato. Health editor Adam Cresswell examines the arguments on either side
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
Supporter: Doctor Michael Nolan uses the ATAPS program, saying his needy patients think the scheme is fantastic’