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Rural Classification and Health Workforce Incentives

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Presentation on theme: "Rural Classification and Health Workforce Incentives"— Presentation transcript:

1 Rural Classification and Health Workforce Incentives
Presentation to General Practice Issues Group 19 June 2009 Sharon Kosmina, RWAV Christine McDonald, GPV Jane Sheats, VHA

2 Presentation Overview
New Classification system and related 2009 budget initiatives Impact on: GP Training Recruitment Retention Practice Funding Support Agencies Health Services Rural Primary Health Services program formed from the: Regional Health Services, More Allied Health Services, Multi Purpose Centres, Building Healthy Communities in Remote Australia New program starts 1 Jan 2010, with 6 month extensions to existing funding arrangements to RHS and MAHS services providers.

3 Classifications and 2009 Budget
New Remoteness Areas classification from 1July 2009 Changes to GP Training General Practice Rural Incentives Program from 1 July 2010 Scaling of Rural Health Workforce Program from 1 July 2010 Rural Primary Health Services Rural Primary Health Services program formed from the: Regional Health Services, More Allied Health Services, Multi Purpose Centres, Building Healthy Communities in Remote Australia New program starts 1 Jan 2010, with 6 month extensions to existing funding arrangements to RHS and MAHS services providers.

4 ASGC-Remoteness Areas Classification
In 2008, Minister Roxon said that RRMA to be reformed so that “incentives and rural health policies respond to current population figures and real need” Geographical classification only Fewer categories and weighted to remoteness on national basis Information on AGSC + Area Locater + Fact Sheets: Rural Primary Health Services program formed from the: Regional Health Services, More Allied Health Services, Multi Purpose Centres, Building Healthy Communities in Remote Australia New program starts 1 Jan 2010, with 6 month extensions to existing funding arrangements to RHS and MAHS services providers.

5 Victorian areas by RRMA
Map supplied by RWAV

6 Victorian areas by ASGC RA

7 RRMA v RA: Indicative Vic GP Numbers
More than 50% of rural GPs were RRMA 5 More than 80% rural GPs are now Inner Regional Data sources: Metro: PHCRIS, Division report Rural: RWAV Annual MDS survey, RRMA 3-7, November 2008

8 Impact of Changes in Classification
Commonwealth claims no losers 2400 GPs across Australia eligible for incentive payments (many in Inner Regional areas) GPs who otherwise lose will retain incentives-unclear for how long. Definition of rurality Little change in Victoria Metro still Melbourne and Geelong; Rural- the rest Some RRMA 1 locations become RA 2 locations Program eligibility criteria and funding formula Unclear- yet to flow through many programs Victoria is Metropolitan and regional, with little remote Will not access larger remote incentives Changes definition of rurality, program eligibility criteria and funding formula Full extent of changes not yet known Commonwealth claims no losers: GPs who would otherwise lose will retain incentives Additional There are winners, but also losers IS THE DEVIL IN THE DETAIL?

9 GP Training Supply of GP Registrars set to increase 594 675 700 812
2009 2010 2011 2012 2013 594 675 700 812 GP Training to change to RA classification New Rural GP Registrar incentives now same as GPs More PGPPP places, but not likely in Victoria GPET to also manage PGPPP from Jan 2010 and new incentives for registrars Sliding scale introduced for HECs payments and changes to scholarship programs in favour of remoteness

10 General Practice Rural Incentive Program
After 0.5 yr 1 yr 2 yrs 3 yrs 5+ yrs RA 1 RA 2 $2,500 $4,500 $7,500 $12,000 RA 3 $4,000 $6,000 $8,000 $13,000 $18,000 RA 4 $5,500 $27,000 RA 5 $47,000 Replaces Rural Registrar Incentives Program and Rural Retention grants

11 Comparison GP Registrar Incentives
Current-RRIP New Implications RRMA 3-7 placements. Rural and General pathways Placements to be based on RA from 1 July 2009 GPET mapping placements from RRMA to RA. Incentives on sliding scale over 3 years based on GPARIA categories GPRIP using RA categories More registrars to be eligible. Significantly less $$ but paid over longer period Rural pathway same as general pathway RRIP After 3 yrs: Cat A: $ 60,000 Cat B: $ 105,000 Cat C: $ 150,000 GPRIP After 3 Yrs: RA 2: $14,500 RA 3: $31,000 RA 4: $44,500 14500 31000 44500

12 Implications More GP Registrars
Significantly reduced rural incentives, but paid over longer time to more registrars No incentive for registrars to train in more remote locations within categories eg Ararat and Ballarat receive the same amount GPET to now be responsible for PGPPP, GP Training and Registrar incentives- better alignment of programs WILL RURAL TRAINING LOSE OUT WITH THESE CHANGES?

13 Recruitment Classification changes Impact on many recruitment programs- yet to know full extent Strategies centre on financial and length of service incentives More city GPs and registrars encouraged to train and work in the country Little incentive for non-resident IMGs

14 New Relocation Incentives
Sliding scale rewards city doctors moving to more remote locations Rural locations gain incentives and outer metro lose incentives No relocation $ for IMGs coming from overseas Current Outer Metro Inner to Outer Metro Existing Practice- $30,000 New Practice- $40,000 Rural None New Relocation Incentives To From RA 2 RA 3 RA 4 RA5 Major Cities $15,000 $30,000 $60,000 $120,000 Inner Regional Outer Regional Remote Former maximum current maximum Shift in relative advantages

15 IMG Service Obligations
IMG Moratoriums - Current RRMA RLRP Australia Five Year Scheme Victoria RRMA 4-7 with DWS Five Year Scheme Other States 3 10 years 4 5 Years 5 years 5 4-5 years 6 10 Years na 3-4 years 7 2-3 years New RA 1 - 2 9 years 3 7 years 4 6 years 5 5 years Victoria worse off if 5 year scheme is removed, but not as much as other States; Victoria RLRP doctors benefit. May increase RLRP turnover?

16 Rural Recruitment programs
Current New Implications Five Year Scheme RRMA 4-7 with DWS To cease? To be replaced by new service obligations Service obligations increased to 6-9 years depending on RA classification – incentive is reduced RLRP RRMA 4-7 and RRMA 3 with DWS Remain RRMA or change to RA? To be RA 2-5? With or without DWS? Moratoriums will reduce for Vic RLRP doctors. International Recruitment RRMA 3-7 with DWS. RHWA contract to 30 June 2009 Program will continue Remain RRMA or change to RA? To be RA 2-5? If not RA 2-5, number of eligible locations will reduce significantly Five Year Scheme IMGs with GP post grad quals or experience RLRP Permanent resident drs International Recruitment Program IMGs not worked in Aust in prior 12 mths

17 Implications for Vic Locations
Melbourne and Geelong No incentives or moratorium benefits Outer metro lose incentives Will lose doctors to RA 2-5 areas if incentives work however Outer Metro relocation incentives, which were at higher $$, had limited effect Regional Cities and RA 2 locations New relocation incentives at RA 2 levels and possible one year moratorium reduction under RLRP Regional locations potentially more attractive than smaller surrounding small towns? Eligibility for MBS rural incentives? RA 3, 4, 5 New relocation incentives rewarding remoteness Reduced moratoriums on sliding scale Might have higher incentives, but will doctors be recruited there? Moratorium (Non-Cash Incentive) Cash Incentives No cash incentives for doctors coming from OS Removal of incentives for doctors moving from inner to outer metro New relocation incentives for doctors moving from metro to rural BUT under old Outer Metro scheme it was difficult to get docs to move to outer metro for $40,000 – RA 2 and 3 is reduced incentive Registrar Training incentives overall have significantly reduced

18 WILL THESE CHANGES GET GPs TO AREAS WHERE THEY ARE NEEDED IN VICTORIA?
Victoria overall Change of RRMA to RA classification need to be RA2-7 or Victorian locations will lose substantial access to recruitment Depends on effectiveness of incentives and the responsiveness of urban doctors to relocate More difficult to recruit non resident IMGs to rural Victoria, which is dependent on IMGs; Will heavily rely on marketing Victoria and HWA initiatives; very little other incentives for IMGs or recruitment WILL THESE CHANGES GET GPs TO AREAS WHERE THEY ARE NEEDED IN VICTORIA?

19 Retention GPRIP payments to apply from 1 July 2010
Retention centres on incentives All areas from RA2 to RA5 are eligible for retention packages on a sliding scale All qualified doctors in the eligible regions qualify provided they meet minimum Medicare requirements. Many new areas in Victoria qualify

20 Revised Retention grants

21 Potentially Eligible GPs
GPAria category Inner Regional Major City Outer Regional Remote Grand Total Ineligible 714 2 40 756 A 209 19 228 B 66 135 201 C 33 3 36 D 989 227 5 1223 RWAV RRMA 3-7 GPs, Nov 2008

22 Comparison After 5 Years
GPARIA RRP payments after 5 years RA GPRIP Payments after 5 years Cat A RA 2 $34,000 Cat B 10,000 RA3 $62,000 Cat C $45,000 RA4 $89,500 Cat D $80,000 RA5 $140,000 Cat E 125,000 Handout Cat A 0 RA 2 $34,000 Cat B 10,000 RA3 $62,000 Cat C $45,000 RA4 $89,500 Cat D $80,000 RA5 $140,000 Cat E 125,000

23 Retention- Implications
Substantial increase in number of eligible GPs in Victoria Significant increases in retention payments No comprehensive focus on factors other than incentives to retain GPs

24 Practice MBS incentives
Current New Implications Rural loading for PIP Practices in RRMAs 3–7 15-50% depending No change If RRMA 1 or 2  RA2 = no benefit Uncertainty about longer term Practice Nurse Subsidy $7 per SWPE p.a. to practices & AMSs in RRMAs 3–7. Capped at $35,000 p.a. As above Item 10991 $8 per consultation to bulk bill concession card holders & under 16 Seen as a critical item for many GPs given high level of concessional payments in rural areas. Practice in RRMA 4 advised that: Expect that under ARIA + may lose the following: Practice nurse subsidy $24,000 Rural loading on PIP payments $15,000 Rural retention payments $20,000 Total $59,000 Consequence will be unable to bulkbill anyone, and will reduce practice nurse hours. Practice nurses (3 PT) do average 160 dressings per month. This work would need to be done by State funded district nurses. In addition all immunisations would need to be done by State funded service. This has not happened but need to keep a close watch + need to advocate. West Vic practice: is the bread& butter of the practice

25 Support Agencies: Divisions
Program Current New Implications Divisions funding $0 per person: RRMA 1 $2.47 per person: RRMA 7 Population weighted by area RA2 – 0.5 RA3 – 1.0 RA4 – 1.5 Likely loss of rural component for RRMA 5  RA2 Workforce Support for Rural GPs Subsidy of 29,200 - $54,700 depending on rural load No change for Will be reviewed for value for money + for efficiency. Expect change for MAHS $3, 770,783 total funds for Victoria Rural Primary Health Services Program Division funds end December 2009

26 Support agencies: RWAV
RRMA 3-7 Current contract concludes June Can include new RA locations but more remote priority New contract to be negotiated during Demands of new RA2 for recruitment & retention support Demands of former RRMAs 4 & 5 to support new models Five Year Scheme IMGs with GP post grad quals or experience RLRP Permanent resident drs International Recruitment Program IMGs not worked in Aust in prior 12 mths

27 Impact on Health Services
Small rural HS linked to GPs Burden on A&E departments Loss of health services weakens community viability Linked to GPs – primary concern of most health services (HS) is the impact on the private clinics if SIPs and PIPs decrease Procedural GPs vital to skills retention & services offered Burden on A&E departments Unfunded A&E cannot operate – block funding & REP payments to VMOs inadequate Funded A&E under strain – if not enough GPs then people go to free A&E Loss of health services weakens community viability Allied health services dependent on Regional Health servcies and More Allied Health Services programs

28 Accident & Emergency Lack of access to GPs
Regional & subregional HS are funded Local health services not funded to provide A&E GPs on-call 24/7 Workload increased over summer months REP Payment to VMOs inadequate Nursing staff EBAs Regional hospitals struggle Lack of access to GPs lead to people seeking services in the A&E, which are not truly emergencies. Local health services not funded to provide A&E, so the GPs on-call 24/7 to provide the service using medicare rebate, as many are set-up as an extention of the GP’s private practice.. Hard to then get VMOs as the Rural Enhancement Package is inadequate to attract rural doctors. ($7 per hour or perdieum $150 weekday, $200 weekends, $250 public hosp. for a 24 hr period) Nursing staff must be provided according to the EBA requiring 2 staff minimum per shift (if an “urgent care service’ , one if it is a “primary care service) and they are not funded for it. However if these close due to GP shortages then the regional hospitals struggle to take the increase in patients.

29 Health Service Concerns

30 Changes to programs Rural Primary Health Services
Regional Health Services More Allied Health Services Multi Purpose Centres Building Healthy Communities in Remote Australia New program starts 1 Jan 2010 Uncertainty creates recruitment and retention problems Rural Primary Health Services program formed from the: Regional Health Services, More Allied Health Services, Multi Purpose Centres, Building Healthy Communities in Remote Australia New program starts 1 Jan 2010, with 6 month extensions to existing funding arrangements to RHS and MAHS services providers.

31 Summary System in transition, with the end point not yet known eg recruitment programs, MBS items, WSRGP, ROMPS Winners: GPs who stay in rural areas RRMA 1 locations who become RA 2 Regional cities access to some programs Losers: Outer metro areas Rural incentives for GP Registrars Former RRMA 5 locations with no competitive advantage to Regional cities RRMA 2 (Geelong) not helped IMGs, especially non resident IMGs What about population and need in classifications? Are we targeting the wrong locations? Heavily reliant on incentives that currently have little evidence basis for success

32 Conclusion Having health workers in remote or rural areas (or any area) relies on two interlinked factors: (a) Factors that influence the decision or choice of health workers to come to, stay in or leave those areas, and (b) The extent to which health system policies and interventions respond to these factors. WHO Background Paper to Expert Meeting Geneva, 2009 Not thought about other measures especially management, environment and social support


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