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
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
2
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
3
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
4
Financing of Primary Medical Care
in Australia
• 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
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
6
Patient coverage of Participating
Practices
Transition payment
First payment under new
arrangements
Change in name
from BPP to PIP
Fe
b
-9
A 5
ug
-9
5
Fe
b9
A 6
ug
-9
6
Fe
b97
A
ug
-9
7
Fe
b98
A
ug
-9
8
Fe
b99
A
ug
-9
9
Fe
b00
A
ug
-0
0
Fe
b0
A 1
ug
-0
1
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
7
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
8
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
9
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)
10
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
11
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
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)
Immunisation rates
Commencement of
incentives
14
Notifications of mumps, Australia,
1991 to April 2002, by date of onset
90
80
Start of GPII
Number notified
70
60
50
Start of GPII
40
30
20
10
0
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
Year
15
[Source: Communicable Diseases Network Australia - National Notifiable Diseases Surveillance System]
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
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
Use of Computers
Tier 1 - Providing program data to
Government
Tier 2 - Use of prescribing software to
generate majority of scripts in the practice
Tier 3 - On site use of computer/s and
modem to send and/or receive clinical
information
$3.00
per SWPE
$2.00
per SWPE
$2.00
per SWPE
19
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)
Patient coverage by PIP practice participation in incentives
100%
Percentage Patients coverage
90%
80%
70%
60%
Tightened guidelines
50%
Electronic prescribing
Data connectivity
40%
30%
20%
10%
0%
Aug-99 Nov-99 Feb-00 May-00 Aug-00 Nov-00 Feb-01 May-01 Aug-01 Nov-01 Feb-02
Payment quarter
21
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
Computing
• The payments gave reasonably generous
incentive for start up systems
• Regional GP organisations (“Divisions”) on
the ground support was important
Care Planning Incentive
• Designed to encourage take up of multidisciplinary 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
Care Plans per quarter
90000
80000
70000
60000
50000
40000
30000
20000
10000
0
1999Q4 2000Q2 2000Q4 2001Q2 2001Q4 2002Q2 2002Q4 2003Q2 2003Q4
25
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
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
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