Presentation on theme: "Rural Classification and Health Workforce Incentives"— Presentation transcript:
1Rural Classification and Health Workforce Incentives Presentation to General Practice Issues Group19 June 2009Sharon Kosmina, RWAVChristine McDonald, GPVJane Sheats, VHA
2Presentation Overview New Classification system and related 2009 budget initiativesImpact on:GP TrainingRecruitmentRetentionPractice FundingSupport AgenciesHealth ServicesRural Primary Health Services program formed from the:Regional Health Services,More Allied Health Services,Multi Purpose Centres,Building Healthy Communities in Remote AustraliaNew program starts 1 Jan 2010, with 6 month extensions to existing funding arrangements to RHS and MAHS services providers.
3Classifications and 2009 Budget New Remoteness Areas classification from 1July 2009Changes to GP TrainingGeneral Practice Rural Incentives Program from 1 July 2010Scaling of Rural Health Workforce Program from 1 July 2010Rural Primary Health ServicesRural Primary Health Services program formed from the:Regional Health Services,More Allied Health Services,Multi Purpose Centres,Building Healthy Communities in Remote AustraliaNew program starts 1 Jan 2010, with 6 month extensions to existing funding arrangements to RHS and MAHS services providers.
4ASGC-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 onlyFewer categories and weighted to remoteness on national basisInformation 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 AustraliaNew program starts 1 Jan 2010, with 6 month extensions to existing funding arrangements to RHS and MAHS services providers.
7RRMA v RA: Indicative Vic GP Numbers More than 50% of rural GPs were RRMA 5More than 80% rural GPs are now Inner RegionalData sources: Metro: PHCRIS, Division report Rural: RWAV Annual MDS survey, RRMA 3-7, November 2008
8Impact of Changes in Classification Commonwealth claims no losers2400 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 ruralityLittle change in VictoriaMetro still Melbourne and Geelong; Rural- the restSome RRMA 1 locations become RA 2 locationsProgram eligibility criteria and funding formulaUnclear- yet to flow through many programsVictoria is Metropolitan and regional, with little remoteWill not access larger remote incentivesChanges definition of rurality, program eligibility criteria and funding formulaFull extent of changes not yet knownCommonwealth claims no losers:GPs who would otherwise lose will retain incentivesAdditionalThere are winners, but also losersIS THE DEVIL IN THE DETAIL?
9GP Training Supply of GP Registrars set to increase 594 675 700 812 20092010201120122013594675700812GP Training to change to RA classificationNew Rural GP Registrar incentives now same as GPsMore PGPPP places, but not likely in VictoriaGPET to also manage PGPPP from Jan 2010 and new incentives for registrarsSliding scale introduced for HECs payments and changes to scholarship programs in favour of remoteness
10General Practice Rural Incentive Program After0.5 yr1 yr2 yrs3 yrs5+ yrsRA 1RA 2$2,500$4,500$7,500$12,000RA 3$4,000$6,000$8,000$13,000$18,000RA 4$5,500$27,000RA 5$47,000Replaces Rural Registrar Incentives Program and Rural Retention grants
11Comparison GP Registrar Incentives Current-RRIPNewImplicationsRRMA 3-7 placements. Rural and General pathwaysPlacements to be based on RA from 1 July 2009GPET mapping placements from RRMA to RA.Incentives on sliding scale over 3 years based on GPARIA categoriesGPRIP using RA categoriesMore registrars to be eligible.Significantly less $$ but paid over longer periodRural pathway same as general pathwayRRIP After 3 yrs:Cat A: $ 60,000 Cat B: $ 105,000 Cat C: $ 150,000GPRIP After 3 Yrs:RA 2: $14,500RA 3: $31,000RA 4: $44,500145003100044500
12Implications More GP Registrars Significantly reduced rural incentives, but paid over longer time to more registrarsNo incentive for registrars to train in more remote locations within categories eg Ararat and Ballarat receive the same amountGPET to now be responsible for PGPPP, GP Training and Registrar incentives- better alignment of programsWILL RURAL TRAINING LOSE OUT WITH THESE CHANGES?
13RecruitmentClassification changes Impact on many recruitment programs- yet to know full extentStrategies centre on financial and length of service incentivesMore city GPs and registrars encouraged to train and work in the countryLittle incentive for non-resident IMGs
14New Relocation Incentives Sliding scale rewards city doctors moving to more remote locationsRural locations gain incentives and outer metro lose incentivesNo relocation $ for IMGs coming from overseasCurrentOuter MetroInner to Outer MetroExisting Practice- $30,000New Practice-$40,000RuralNoneNew Relocation IncentivesToFromRA 2RA 3RA 4RA5Major Cities$15,000$30,000$60,000$120,000Inner RegionalOuter RegionalRemoteFormer maximum current maximumShift in relative advantages
15IMG Service Obligations IMG Moratoriums - CurrentRRMARLRPAustraliaFive Year SchemeVictoriaRRMA 4-7 with DWSFive Year Scheme Other States310 years45 Years5 years54-5 years610 Yearsna3-4 years72-3 yearsNewRA1-29 years37 years46 years55 yearsVictoria worse off if 5 year scheme is removed, but not as much as other States; Victoria RLRP doctors benefit. May increase RLRP turnover?
16Rural Recruitment programs CurrentNewImplicationsFive Year SchemeRRMA 4-7 with DWSTo cease?To be replaced by new service obligationsService obligations increased to 6-9 years depending on RA classification – incentive is reducedRLRPRRMA 4-7 and RRMA 3 with DWSRemain RRMA or change to RA?To be RA 2-5?With or without DWS?Moratoriums will reduce for Vic RLRP doctors.International RecruitmentRRMA 3-7 with DWS.RHWA contract to 30 June 2009Program will continue Remain RRMA or change to RA? To be RA 2-5?If not RA 2-5, number of eligible locations will reduce significantlyFive Year SchemeIMGs with GP post grad quals or experienceRLRPPermanent resident drsInternational RecruitmentProgramIMGs not worked in Aust in prior 12 mths
17Implications for Vic Locations Melbourneand GeelongNo incentives or moratorium benefitsOuter metro lose incentivesWill lose doctors to RA 2-5 areas if incentives work however Outer Metro relocation incentives, which were at higher $$, had limited effectRegionalCities andRA 2locationsNew relocation incentives at RA 2 levels and possible one year moratorium reduction under RLRPRegional locations potentially more attractive than smaller surrounding small towns?Eligibility for MBS rural incentives?RA 3, 4, 5New relocation incentives rewarding remotenessReduced moratoriums on sliding scaleMight have higher incentives, but will doctors be recruited there?Moratorium (Non-Cash Incentive)Cash IncentivesNo cash incentives for doctors coming from OSRemoval of incentives for doctors moving from inner to outer metroNew 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 incentiveRegistrar Training incentives overall have significantly reduced
18WILL THESE CHANGES GET GPs TO AREAS WHERE THEY ARE NEEDED IN VICTORIA? Victoria overallChange of RRMA to RA classification need to be RA2-7 or Victorian locations will lose substantial access to recruitmentDepends on effectiveness of incentives and the responsiveness of urban doctors to relocateMore 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 recruitmentWILL THESE CHANGES GET GPs TO AREAS WHERE THEY ARE NEEDED IN VICTORIA?
19Retention GPRIP payments to apply from 1 July 2010 Retention centres on incentivesAll areas from RA2 to RA5 are eligible for retention packages on a sliding scaleAll qualified doctors in the eligible regions qualify provided they meet minimum Medicare requirements.Many new areas in Victoria qualify
22Comparison After 5 Years GPARIARRP payments after 5 yearsRAGPRIP Payments after 5 yearsCat ARA 2$34,000Cat B10,000RA3$62,000Cat C$45,000RA4$89,500Cat D$80,000RA5$140,000Cat E125,000HandoutCat A 0 RA 2 $34,000Cat B 10,000 RA3 $62,000Cat C $45,000 RA4 $89,500Cat D $80,000 RA5 $140,000Cat E 125,000
23Retention- Implications Substantial increase in number of eligible GPs in VictoriaSignificant increases in retention paymentsNo comprehensive focus on factors other than incentives to retain GPs
24Practice MBS incentives CurrentNewImplicationsRural loading for PIPPractices in RRMAs 3–715-50% dependingNo changeIf RRMA 1 or 2 RA2 = no benefitUncertainty about longer termPractice Nurse Subsidy$7 per SWPE p.a. to practices & AMSs in RRMAs 3–7. Capped at $35,000 p.a.As aboveItem 10991$8 per consultation to bulk bill concession card holders & under 16Seen 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 $24,000Rural loading on PIP payments $15,000Rural retention payments $20,000Total $59,000Consequence 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
25Support Agencies: Divisions ProgramCurrentNewImplicationsDivisions funding$0 per person:RRMA 1$2.47 per person:RRMA 7Population weighted by areaRA2 – 0.5RA3 – 1.0RA4 – 1.5Likely loss of rural component for RRMA 5 RA2Workforce Support for Rural GPsSubsidy of 29,200 - $54,700 depending on rural loadNo change forWill be reviewed for value for money + for efficiency.Expect change forMAHS$3, 770,783 total funds for VictoriaRural Primary Health Services ProgramDivision funds end December 2009
26Support agencies: RWAV RRMA 3-7Current contract concludes June Can include new RA locations but more remote priorityNew contract to be negotiated duringDemands of new RA2 for recruitment & retention supportDemands of former RRMAs 4 & 5 to support new modelsFive Year SchemeIMGs with GP post grad quals or experienceRLRPPermanent resident drsInternational RecruitmentProgramIMGs not worked in Aust in prior 12 mths
27Impact on Health Services Small rural HS linked to GPsBurden on A&E departmentsLoss of health services weakens community viabilityLinked to GPs – primary concern of most health services (HS) is the impact on the private clinics if SIPs and PIPs decreaseProcedural GPs vital to skills retention & services offeredBurden on A&E departmentsUnfunded A&E cannot operate – block funding & REP payments to VMOs inadequateFunded A&E under strain – if not enough GPs then people go to free A&ELoss of health services weakens community viabilityAllied health services dependent on Regional Health servcies and More Allied Health Services programs
28Accident & Emergency Lack of access to GPs Regional & subregional HS are fundedLocal health services not funded to provide A&EGPs on-call 24/7Workload increased over summer monthsREP Payment to VMOs inadequateNursing staff EBAsRegional hospitals struggleLack 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.
30Changes to programs Rural Primary Health Services Regional Health ServicesMore Allied Health ServicesMulti Purpose CentresBuilding Healthy Communities in Remote AustraliaNew program starts 1 Jan 2010Uncertainty creates recruitment and retention problemsRural Primary Health Services program formed from the:Regional Health Services,More Allied Health Services,Multi Purpose Centres,Building Healthy Communities in Remote AustraliaNew program starts 1 Jan 2010, with 6 month extensions to existing funding arrangements to RHS and MAHS services providers.
31SummarySystem in transition, with the end point not yet known eg recruitment programs, MBS items, WSRGP, ROMPSWinners:GPs who stay in rural areasRRMA 1 locations who become RA 2Regional cities access to some programsLosers:Outer metro areasRural incentives for GP RegistrarsFormer RRMA 5 locations with no competitive advantage to Regional citiesRRMA 2 (Geelong) not helpedIMGs, especially non resident IMGsWhat about population and need in classifications? Are we targeting the wrong locations?Heavily reliant on incentives that currently have little evidence basis for success
32ConclusionHaving 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, 2009Not thought about other measures especially management, environment and social support