Workforce reform is crucial to the cost-effectiveness of our health system and yet is often omitted from discussions of health system funding. In the following article, Professor Peter Brooks argues that reform of our fee-for-service payment system must be considered as part of a broader discussion about the future sustainability of our health system. This piece was originally published on John Menadue’s blog Pearls and Irritations and is re-posted here with permission.
Professor Brooks writes:
As we draw to the end of the holiday period and contemplate the challenges for us in 2014, we might take a moment to think about the big questions in health. We are continually reminded by politicians, media and other (self) interested groups about the cost of health care, the need for more doctors and nurses, more beds, more money -all of which will blow out the health budget even more. We are told that patients will have to pay more (the proposed $6 fee for GP visits) but rarely do we look at what are the real ‘drivers‘ in the costs of health care. Doctors have a very privileged position in society but we are responsible for generating the bulk of costs of healthcare – every time we order a test, prescribe a medication, recommend a procedure, and admit a patient to hospital costs are generated, so surely we need to look at this side of the equation. This is particularly so in the context of the Australian health system which is based on fee for service – every time there is an interaction with the medical profession the cash register tinkles!
So overall doctor numbers are important – because we –the doctors – generate the bulk of these costs. The ‘system’ is set up so that many things that doctors do which could be done by someone else at less cost – pharmacist/nurse practitioners writing repeat prescriptions, doing vaccinations and other minor procedures are not well supported. The most recent data from Health Workforce Australia present a number of scenarios on doctor numbers from having 2,700 too few in 2025 if we make no change in how we deliver health services (we couldn’t be that silly) to having 2,800 too many if we make a modest improvement in doctor ‘productivity’. This could be easily achieved by transferring some tasks to other members of the health care team and better utilising telehealth and other communication technologies. If we really got serious about health promotion and disease prevention (now that is a novel thought) and reduced demand by just 2% (which is really not very much) we would have a surplus of over 18,000 doctors in 2025- what a waste of talent.
Now proponents for having more doctors say – “but it is so hard to see a GP when I need one” and rural general practice is still undersupplied – true – but there may be other ways of incentivising doctors to work in rural areas or using different models of care – linking local nurse practitioners or physician assistants with GPs /Specialists in regional centres to provide appropriate geographical coverage across this wide brown land. Health care is very complex – we don’t think about it till we need care and then it is often too late to even think about choice. With the ageing population all of whom will have chronic disease we have a great opportunity to plan better than we have up until now – to think about a health system that is fair and equable not just for those who can afford it but for all.
We also (and the medical profession needs to be at the for front of this particular issue ) need to clearly evaluate what should be provided for an individual patient – not just because the procedure or intervention is available – but ask if it will really improve that patient’s health – and ensure that the patient can be involved in that decision. But fundamental to the future of the health system in Australia is how we pay for health services – fee for service needs to be reviewed since it is not sustainable in the medium to long term. There are many other systems we might consider – salaried (and interestingly America now has more salaried doctors than non-salaried), a variety of insurance schemes including health savings accounts, capping fees in some form – so why don’t we talk about this in a serious way?
Tinkering around the edges in the form of a $6 payment for GP visits which is estimated to save around $700 million over a 4 year period out of a $130 million annual health budget and creating real pain for many less well-off Australians is a bad idea – but it does provide an opportunity to start a real community debate on what the other alternatives are – and there are many. This should be about real change in the health system – to ensure one of the better health systems in the world remains accessible to ALL Australians and that patients are fully informed of their health options and are engaged in those individual health decisions.
Peter Brooks AM MD FRACP is Director of the Australian Health Workforce Institute at the University of Melbourne. He has published widely in musculoskeletal diseases and more recently in health care and health workforce reform.