1. Incentives in Australian Primary Medical Care Peter Broadhead I’m grateful to Ian McRae, who provided some of the slides used in this presentation. Views expressed are those of the author and not necessarily those of the Australian Department of Health and Ageing

2. 2 Financing of Primary Medical Care in Australia Medical care outside hospitals is fee for service, by doctors in private practice Federal government is single payer, providing indemnity cover, funded from general taxation –No private insurance permitted for out-of-hospital medical fees –No limit to fees doctors can charge –Government pays rebates per item at 85–100% of a national fee schedule

3. 3 Financing of Primary Medical Care in Australia Roughly half of all doctors are ‘general practitioners’ –Primary care physicians working in offices For 73% of GP attendances, zero out of pocket costs (reflects price competition in cities) GPs are ‘gatekeepers’ –fees for specialist services only eligible for rebates if initially GP referred

4. 4 Financing of Primary Medical Care in Australia GPs generally work in small practices –average practice size of 2.5 - 3.0 On average Australians go to a GP five times a year –Also have four pathology items –and see a specialist once a year In 4 out of 5 GP visits, people are prescribed medications

5. GP funding is broadly : –$A2.90b government rebates –$A0.40b patient co-payments –$A0.23b government incentives payments –$A0.8b (estimated) from other work Approximate average annual full time earnings (net of practice costs) are : –$130,000 from fee for service –$A17,000 from incentives Financing of Primary Medical Care in Australia

6. 6 Specific Financial Incentives Government introduced a program of specific financial incentives for GPs in 1995 Participation voluntary Not welcomed by organised profession –very strong allegiance to fee for service –But attraction of additional marginal revenue outside FFS price competition did see uptake over time Reviewed and revised in 1998 Additional specific incentives introduced over time. Around 8% of government payments for GP services

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8. 8 Specific Financial Incentives Practices/doctors register to participate Participation is voluntary Practices must be accredited (or achieve accreditation within 12 months) to be eligible to participate Practices must agree to provide data Practices are paid for participating, even if they do not qualify for any specific incentives

9. 9 Specific Financial Incentives Electronic prescribing Electronic transfer of some clinical data Access to ‘after hours’ care – 3 tiers –Ensuring patients have access to 24 hour care –Provision of at least 15 hrs/week of after-hours care from within the practice –Provision of all after hours care for practice patients Teaching: Hosting Medical Students

10. 10 Specific Financial Incentives Childhood immunisations Asthma care Cervical Screening Diabetes care Mental health care Quality Prescribing –Clinical audit, academic detailing, education Care Planning (in 2001 and 2002 only) Practice Nurses (employment of)

11. 11 Specific Financial Incentives Payments are based on practice size –measured in Standardised Whole Patient Equivalents (SWPE) Many people go to more than one practice, only that proportion of a person’s care delivered by a practice counts towards the practice’s size Roughly 1000 SWPE per full time GP With loading for rurality –up to 50 % for remote

12. Specific Financial Incentives Most payments are for process improvements Few payments are for outcomes –And these are generally intermediate outcomes Actual effects of incentives are difficult to determine –No control groups –Multi-factorial causation Examine three to illustrate –childhood immunisations –Computerisation (IM/IT) –care planning

13. Immunisation GP financial incentives one part of a package also including –education programs for GPs –national league tables of GP performance by region –financial incentives for parents –publicity campaign for immunisation –A national child immunisation register Service incentive payments to GP for completing vaccination ($18.50 per completion) Outcome payment to practice for achieving > 90% for children attending practice. –(avg ~$3600 pa per practice, by 2002-03)

14. 14 Commencement of incentives Immunisation rates

15. Start of GPII 15 Notifications of mumps, Australia, 1991 to April 2002, by date of onset [Source: Communicable Diseases Network Australia - National Notifiable Diseases Surveillance System]

16. Immunisation It is a “cause” which no one opposes The targets were seen as reasonable and were achievable While total payments are not huge, payment per activity is quite generous

17. Immunisation Feedback led to a competitive situation which, anecdotally, contributed to outcomes The role of regional support organisations for “on the ground” support and education was important to GP engagement

18. Immunisation While target is 90+%, GPs perform only 70% of immunisations, on average. Independent evaluation in 2000 found it difficult to tease out various effects, but concluded a major factor was the financial incentives for parents

19. 19 Use of Computers Tier 1 - Providing program data to Government $3.00 per SWPE Tier 2 - Use of prescribing software to generate majority of scripts in the practice $2.00 per SWPE Tier 3 - On site use of computer/s and modem to send and/or receive clinical information $2.00 per SWPE

20. Use of computers Electronic prescribing grew from: –10-20% before the program –to 51% as the program commenced –to 94% of participating practices (Nov 2005)

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22. Computing Existing trend to greater computerisation Support of the industry helped considerably with the raising awareness There was general support for the benefits particularly of electronic prescribing to improve quality and minimise problems of prescribing inappropriately

23. Computing The payments gave reasonably generous incentive for start up systems Regional GP organisations (“Divisions”) on the ground support was important

24. Care Planning Incentive Designed to encourage take up of multi- disciplinary care planning Payment for undertaking plans for a prescribed percentage of eligible patients Payment very generous per service Take up became enormous, once targets understood, but with very poor adherence to guidelines

25. 25 Care Plans per quarter

26. Other Issues Sustained campaign of criticism from organised profession about “red tape” (ie too much bureaucracy) Specialisation concerns – GPs focusing on maximising incentive payments at the expense of other necessary care Difficult to reduce incentives once introduced Measurement challenges –To implement incentives –To evaluate independent effects of incentives

27. Discussion Assessing the independent effects of specific incentives is a difficult challenge Specific financial incentives are very attractive to policy makers –Hard to contest ‘rewarding the good’ Cost can be small –Especially if funds for incentives are within the level of total payments that would otherwise have been made

28. Discussion Objectives need to be accepted as worthwhile Competition and feedback are beneficial –League tables of performance Avoid making the package too complex Information/education for practitioners is critical Robust systems for data capture are essential