Health economist Gavin Mooney has two offerings for Croakey readers.
For those with an interest in citizen’s juries and their potential for informing health policy and related decisions, he has just released A Handbook on Citizens’ Juries, which sets out their pros and cons, how to run them, and gives some examples of their use in Australia. It is freely available here.
Mooney has also taken up the previous Croakey post on fee for service, and suggests that citizen’s juries may be able to help inform policy about remuneration systems. After all, if we don’t know what the community really wants from GPs, how can we know what is the most useful way of paying them?
“Fee–for-service has the problem that it is just that: the more the doctor (for example) does the more he/she gets by way of income. What’s wrong with that? Well piece work (which is what it is) just doesn’t seem quite right for the noble profession. But there are other arguments here.
What is striking in any debate about how to pay doctors (and other health care professionals) is just how little remuneration systems are seen as instruments of health policy. Yet what evidence there is suggests that what doctors do can be influenced by how they are paid. I see no problem with that – doctors are human and respond as we all do to economic incentives.
Some years ago in Denmark together with four Danish doctors, I was involved in a study that looked at the impact of a change in remuneration of GPs in Copenhagen. They moved from capitation (being paid according to the size of the population served, whether the citizens became patients or not) to part capitation, part fee for service. The payments were from the state; the patients paid nothing.
What happened? Well in some respects at least the GPs changed their practices quite markedly. While they did not treat more patients, they treated patients more. And they referred far fewer patients to hospital and to specialists. The fee per minute for different services was not constant and those services which paid most per minute increased most.
One interesting aspect of this was that when we reported the results to the Danish media, they were surprised at two levels. One, that doctors responded to financial incentives and two, that the four doctors involve with me in conducting the study were admitting this!
I don’t see anything wrong at either level. What was a problem is that we could not tell whether the new was better than the old as no one knew what the objectives were of Copenhagen general practice!
The key things on this front in Australia are experimentation and flexibility. There are two issues here. One size does not fit all as Croakey has indicated.
But second we need to find out what patients and potential patients (i.e citizens) want from, for example, their GPs (for example using citizens’ juries) and then to try to design a remuneration system that will deliver that.
What citizens in metro areas want and what citizens in remote areas want may well differ and then so too will the remuneration system. Where more public health is wanted, capitation may be the answer; where more screening, target payments where GPs get large rewards once they screen say X% of their target population; and so on.
FFS may be part of either or both the metro system and the remote system – who knows. But where to start is to find out what informed citizens want from their (in this example) GPs and then design the remuneration systems accordingly. It is that information – what folks as informed citizens want from their GPs – that is missing.”
• Gavin Mooney is Honorary Professor, University of Sydney.
BTW, this is what John Menadue, Director, Centre for Policy Development, and Professor Stephen Leeder, Director, The Menzies Centre for Health Policy, have said in their endorsements of the new book.
John Menadue states:
”Vested interests, the AMA, private health insurance companies, pharmacists and pharmacy distributors rely on their lobbying power with governments to secure their interests. Unlike almost any other industry, the community is effectively excluded from important influence and decision-making in the way our health services are structured and delivered. Citizens’ juries can be an important means at both national and local level to facilitate effective participation by the community in health services. Professor Gavin Mooney continues to be an outstanding advocate of the proposition that health services should focus on the needs of the community and patients rather than providers.”
Stephen Leeder says:
“Citizens’ juries have a long and distinguished pedigree in assaying community attitudes, values and contributions. Their use in health service development is relatively recent, and holds much promise as increasingly we appreciate the necessity for citizens – patients, carers and the community more generally – to help make decisions that align health care resources more closely to health needs and social values. This book, from Gavin Mooney, who has facilitated more citizens’ juries in health in Australia than anyone else I know, will be most useful to those who want to run such a jury but are unsure how to go about it.”