Fri Feb 3

Medicare reform is off to a promising start. Now comes the hard part

Written by Peter Breadon, Program Director, Health and Aged Care, Grattan Institute

medicare card and australian currency in background

There was a lot of build-up to today’s National Cabinet meeting ^[1]. Federal Health Minister Mark Butler has long said ^[2] Medicare is in the worst shape it has ever been, and the premiers said ^[3] health reform should be the top priority at the meeting.

Soon after taking office, Butler appointed a Strengthening Medicare Taskforce ^[4] to advise on how to fix a system everyone agrees is in crisis. It includes the industry groups for GPs, nurses and allied health workers, as well as academic experts and a patient advocate. Today, the taskforce’s final report ^[5] was discussed at National Cabinet and publicly released.

It’s only 12 pages long and light on detail, but it lays out clear directions and includes big reforms. While there have been many calls to throw more money into the existing system, the taskforce recommends a trickier, but necessary, course toward the structural, long-term reform general practice needs.

The taskforce’s recommendations fall under four themes: funding reform, multidisciplinary team-based care, data and IT, and supporting change.

Funding reform to improve access to care

The way Australia funds general practice is stuck in the past, and the taskforce recommends a big overhaul.

Today, we have a fee-for-service model which rewards doctors for seeing lots of patients for short, one-off visits.

But Australians have got older and sicker since Medicare was designed 40 years ago. Many of us require longer consultations. There is strong evidence that people will be healthier ^[6] and live longer ^[7] if they have ongoing relationships with their care team, not just one-off visits.

Another problem is the current funding model doesn’t do enough to ensure health care is delivered in communities with less access to care, including to First Nations Australians, people in rural and remote areas, and people on low incomes.

The taskforce recommends a move to “blended” funding models to overcome these challenges. These models mix visit fees with other types of payments, such a flexible budget for each patient and payments for providing quality care.

The taskforce also recommends voluntary patient registration, where patients are linked with a “home” practice, so they build a relationship with their usual health care providers.

Encouraging multidisciplinary care

Australia’s current model of general practice doesn’t give GPs enough support.

There are many primary care workforces, such as nurses and allied health workers, whose training means they can help GPs manage a growing and more complex caseload. But as it stands, our rules, regulations, and funding model ^[9] limit the help they can provide.

Changing this will bring big benefits. It can help take pressure off busy GPs, giving them more time for complex cases. And the evidence suggests it can boost quality of care ^[10] and health outcomes ^[11].

Medicare was designed 40 years ago and needs an update. Shutterstock ^[12]

The taskforce recommends the federal government work with the states to remove regulatory barriers that stop primary care professionals from using all their skills.

It calls for more investment to help build these new teams into GP practices, and for Primary Health Networks (the regional organisations that are responsible for improving the primary care system) to deploy nurses and allied health workers to GP clinics where they are most needed.

Improving data and digital systems

The right data and digital tools can let primary care teams know when their patients have been in hospital, or had new care recommended by other doctors. They can help practices provide the best care, help patients manage their own health, and help government understand how the system is performing.

But these systems are not working well. Australia’s digital health platform, My Health Record, is not user-friendly and few clinicians use it ^[14].

Progress in linking up data from Commonwealth and state systems has been agonisingly slow ^[15].

The taskforce calls for improvements to the My Health Record system, making sharing of information from providers the default, and making the system easier for clinicians and patients to use.

The taskforce proposes joining up health data, with new national governance, legislation, regulations and technology.

It also suggests new investment in IT infrastructure and skills for clinics, and building up digital health literacy for patients.

Supporting change management and cultural change

All of this calls for big shifts in how general practice operates. It’s easy to underestimate how hard change is for general practices, many of which already report high levels of stress and burnout.

New funding models and multidisciplinary team-based working go beyond simple tweaks to processes. They involve new ways of thinking about roles, responsibilities, and relationships.

Past attempts at general practice reform have shown just how hard the journey can be. Australia’s last attempt was the Health Care Homes trial ^[17], which ran from 2017 to 2021. It had trouble attracting general practices to participate, and problems with patients and practices dropping out.

The taskforce highlights that the reform journey for primary care can’t be rushed. It recommends a staged approach, supported by evaluation, and with patients and communities at the centre of policy and delivery.

It recommends supporting clinics to help them manage change. That includes training for practice managers so they can help practices transition to new ways of working.

Good digital tools can let GPs know when their patients have been in hospital. AAP Image/Diego Fedele ^[18]

What now?

Minister Butler remarked ^[19] that the health sector has “a lot of loud voices and sharp elbows”.

Some groups have been quick to criticise the taskforce report. The Australian Medical Association ^[20], which represents doctors, said the report wouldn’t have an immediate impact for people who were struggling to get care. The professional body for GPs welcomed ^[21] much of the report, but has also called for an immediate boost to funding, and cautioned GPs must lead any health care team. The allied health body has criticised ^[22] the focus on building up teams inside GP clinics.

But this report could never satisfy everyone, or solve every problem.

What the taskforce proposes amounts to the biggest change to general practice in generations. It has recognised tinkering, or even a couple of big reforms, won’t heal a broken system. The proposals rightly span across funding models, workforce roles, and digital systems. And the taskforce emphasises change will be hard, take time, and should be guided by the voices of patients, clinicians, and communities.This is the right approach to a very complex challenge.

There will be more detail on these reforms in the upcoming budget, but Minister Butler has said it will take years of investment to fix the crisis in general practice.

There is a lot more work needed to flesh out this vision, but it is a promising start.