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Episode 2 - Dr McMullen on the AMA's plans for GP reform
92 Plays1 month ago
AMA President Dr Danielle McMullen talks with Dr Omar Khorshid and Dr Chris Moy about the need to reform general practice funding and structure and the AMA's propsals to ensure the longevity of general practice in Australia.
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Transcript
Introduction to Australian Healthcare Reform
00:00:00
Speaker
Welcome to The Waiting Room, the podcast where we explore the pulse of Australian healthcare. You're listening to The Waiting Room, a podcast by Australian Medical Association, with your hosts, Dr Omar Khorshid and Dr Chris Moy.
00:00:16
Speaker
I'm Dr Omar Khorshid.
00:00:25
Speaker
And I'm Dr Chris Moy, a GP, and ah we're about to dive into a topic close to my heart, which is the AMA's blueprint for reforming general practice and 2025 to pre-budget submission.
00:00:40
Speaker
regarding general practice because general practice has been and I hope still remains the cornerstone of our health system that's I think we all understand under increasing
General Practice Policy and Election Investments
00:00:50
Speaker
pressure. And joining us to go through and do this deep dive on general practice policy here for the second time in our second episode is Dr Danielle McMullen, President of the AMA. Danielle, welcome back. Thanks for having me. And we've already heard about the big investments and announcements in general practice that occurred during the election campaign, but of course there's much still to do. Chris, do you want to start the process of interrogating the AMA's policies? I think I can honestly say that many of my colleagues, despite the record investment in general practice on a day-to-day basis, are incredibly frustrating and actually seething. many
00:01:27
Speaker
you know I had a talk with a GP recently, wanted to Now, I think it was partly other issues, things like payroll tax, which is obviously state issue, but they really feel so frustrated that they they often want to leave the system, which is is is terrible.
00:01:41
Speaker
I suppose the question is, is why have we gotten know where are we at the moment? why and you know Why are we in this terrible position and and what are the core issues that that we need to solve? It's a great question and I think you you got to it there, that really general practice is feeling in a precarious state at the moment and it feels...
00:01:59
Speaker
You and I both GPs and I think the past few years has really felt like a death by a thousand cuts and think even before the pandemic hit, um general practice was being faced with, as everyone is, an aging population, more chronic disease, more complex care and your average consultation time slowly creeping up.
Challenges Faced by GPs During the Pandemic
00:02:20
Speaker
Then of course, you know, we had the pandemic and every day there were a new set of rules and guidances and as small business owners and and small practices that governance of having to change your workflow every five seconds was really exhausting and particularly early in the pandemic there really was a poor recognition of the impact that was having on general practice and the importance of general practice as a frontline And to me, that's when I think um it really started unraveling and I've had a ah growing sense since then that general practice is quite rightfully her feeling hard done by.
00:02:59
Speaker
um The workload is high, the patient expectations are high, and yet we have a Medicare system that doesn't meet the needs of today because now, yes, the pandemic has by and large passed us by and it's back to pretty much business as usual, but we now have telehealth, we've got different models of care, we've got ah novel intruders, so to speak, of these direct-to-patient marketing, single-issue online clinics,
00:03:27
Speaker
um We have had changes, as you said, to payroll tax, to scope of practice in in pharmacies and other groups taking on what used to be general practice work. So I think general practice is feeling quite vulnerable. um And despite having a primary care 10-year plan at a Commonwealth level,
00:03:44
Speaker
and the strategic the Strengthening Medicare Task Force, they're really yet to see that translate into tangible benefits. And so we're in a difficult spot where general practice is still relatively underfunded for the complexity of care we provide.
00:03:59
Speaker
And so the AMA has been working hard over the past few years to turn these big strategic documents into practical policy options that we would encourage government to pick up or at least to take the key highlights out of ah to make sure that we've got the workforce and the supports that we really need to deliver that general practice care to the population.
00:04:20
Speaker
So it really sounds like one of these wicked problems and they're they're just so difficult to solve because they're so large both in dollar terms but also complexity, many, many different issues that need to be addressed.
00:04:32
Speaker
wheres Where's your focus? what's What's your number one priority right now for the AMA in the general practice area?
Exploring Funding Models for Medicare Reform
00:04:38
Speaker
As you said, it's a complex problem that requires a complex solution and I've i've done away with being able to think that there's a silver bullet um and and I don't think there is one answer that would fix it and I know that's sometimes hard to hear but we do have a suite of solutions. It's also hard for an alternative hopeful and There should be a simple solution to any problem.
00:05:00
Speaker
ah But I think, you know, the the more we keep trying to find this one thing that's going to fix it, it's just not going to work in general practice. But we do have a suite of solutions that would fix it. So we do, yeah and that's what we've tried to articulate through modernised Medicare, um which is the public-facing campaign. But behind that is a whole lot of policy um that recognises that fee-for-service remains and will remain the bedrock of general practice funding.
00:05:26
Speaker
And what I mean by that is that, know, you're patient comes in, you see them for a consultation and there's a payment for that consultation and service. But the current structure of that doesn't meet today's needs, but also probably no structure of that meets all the needs for really unwell patients or for very remote communities or kind of different sorts of practices that are out there.
00:05:46
Speaker
And so we're also open to exploring some other funding models where you might get paid a block of funding for some parts of care or increased block funding for allied health that might work in your practice.
00:05:58
Speaker
In fact, we're calling on a boosted payment to get more nurses and allied health into general practice and that we also know to really drive those reforms need better data under underlying that to show to demonstrate funders want to know what you're doing with their money and so we really need that data to be able to show them demonstrate what it is that's happening inside that consultation room and obviously we need the workforce for the future And so another arm of modernised Medicare is is how to drive that workforce and boost that workforce going forward.
00:06:30
Speaker
um So, yeah we have cut it down into digestible chunks of policy, um but I think we are also pushing government to recognise that one set of reforms or one piece of policy is not going to solve general practice in Bondi and also out the back of Burke.
00:06:47
Speaker
So we had this election campaign where the government came up with this triple billing incentive for all and put in a lot of money into this ah which was something which from general practice I think we really realised on the ground that wasn't the solution that we needed.
00:07:03
Speaker
um It was nice to have that increased funding but it wasn't going to solve things because the Medi-Key rebate is so far away from where it needs to be and also it structure doesn't work.
00:07:15
Speaker
um In terms of the yeah two thousand and twenty five twenty six pre-budget submission, um how do we get from there where they've already put this large amount of money in to massage them and and and what are we trying to massage them into to try and open their eyes to a different world?
00:07:33
Speaker
How do we get the government to move into that position, especially at the moment given the fact they're probably resting on their laurels after winning a big election? Exactly. But we've heard from the health minister himself that he's still using the word reform and still open to hearing about reform. So while we weren't, you know, it was huge investment in the election, but not the reforms we had asked for, we have the options of either, you know, being despondent about it or looking at the opportunities to keep fighting. And that's clearly what we'll do as the AMA.
00:08:04
Speaker
And we do have opportunities. So one of the core asks in our modernised Medicare campaign was a restructuring of the MBS items. And there is, in fact, an MBS committee at the moment looking at time-tiered items in general practice. So we have an active mechanism to be able to still be putting this policy platform forward.
00:08:23
Speaker
And really what that's about is to re to smooth the curve of patient rebates when they go see the GP. and reduce that disincentive for longer consultations. Because at the moment, under the current structure,
00:08:36
Speaker
um yeah and not to really drill it down to a per minute basis, but the patient rebate for a shorter consultation is relatively speaking much higher than it is for a medium or a longer consultation.
00:08:48
Speaker
And yet we know from um data that the RACGP gathers that the average consultation length is now creeping up to that sort of 18, 19 minute mark. And at the moment, the patient gets the same Medicare rebate, whether they're in the room for 10 minutes or 19 minutes. And that really doesn't make sense um when your average consultation length is at the higher end of that. So we're really trying to articulate to decision makers and to patients and to funders that they need to be investing. not We're not talking long consultations like an hour or more. It's really that sort of 15 to 35 minutes where you can deal with a couple of issues, a number of issues um in a comprehensive way and really take better care of patients. But
Consultation Frameworks and Data Utilization
00:09:33
Speaker
at the moment, the funding really doesn't match. So that's our key goal is to keep pushing for that change in structure.
00:09:39
Speaker
And um we do have some active mechanisms to be able to do that moving forward. I feel it acutely because I realise that a lot of my patients, because they have trouble seeing me, they come in with lists.
00:09:50
Speaker
They come in with a dreaded list. Oh, my God. I had a patient the other day who only needed a script refill and my jaw nearly dropped and hit the floor and I even looked to see if they, you know, maybe needed some screening, but they were genuinely up to date with everything else.
00:10:04
Speaker
I was so excited. I think they wondered why I had this giant grin on my face, but I was running very late and it was the greatest part of my day, but it's ah few and far between. Could I say, though, that, you know, look we've been down this line before, we're trying to reform the MBS.
00:10:20
Speaker
um And the problem is, is we've spent the, you know, the way that MBS has been funded in general practice has really favoured the short consultations and high throughput medicine for so long. And it's actually, to some degree, unfortunately, general practice in some areas has actually sort of but been pushed into that that model to a great degree and in certain areas. Now, the problem is, isn and and I see politically from you, that that you mentioned two things, this reform of the MBS, but also potential for block funding and changes in funding, which I think all makes sense to try and sort of change the way that general practice is funding for chronic disease. But um how do you navigate the issues of, number one, potential winners and losers in this?
00:11:02
Speaker
and also the fear that general practice always has of capitation, you know, the block funding and capitation and what's the difference, the idea that we might be heading towards a... And that's that's a common discussion point amongst many, many for example, our colleagues who are coming from the UK, for example. Danny, if I could just add to Chris's question around winners and losers, ah you've just got $9 billion into general practice, albeit not in the right structure.
00:11:30
Speaker
Are you willing to have a conversation with government about reform of the items that doesn't actually cost them anything, that is internally cost neutral, and in which case they would absolutely be winners and losers? Is that on the agenda or is that impossible to discuss?
00:11:45
Speaker
At the heart of all of that and the fears around capitation and winners and losers is the fact that no system works if it's underfunded. i don't care what your funding structure is, if you're not putting enough into it then it's going to fail.
Patient Enrolment and Care Delivery
00:12:00
Speaker
um So our primary goal, regardless of the structures, needs to be ensuring that there's robust things for indexation and that we're adequately funding the work that's being done.
00:12:12
Speaker
And then we get back to thinking about, okay, well, what is the funding structure that makes the most sense? Now, Australia has been, in general practice, nearly 100% fee-for-service. And every funding model has its pros and cons.
00:12:26
Speaker
um Obviously, under that that model, and there is kind of innate incentive to do more stuff. The more you do, the more you get paid in a fee-for-service model.
00:12:37
Speaker
And in a fully block-funded model, there's an inherent risk of doing less stuff because you're not necessarily pushed to kind of drive that activity.
00:12:48
Speaker
And we've got to find that balance because at the moment the fee-for-service probably doesn't meet all the needs of our most complex patients where we need team-based care, we need to do more non-face-to-face time.
00:12:59
Speaker
and But at the same time, there's no way that Australia needs to or wants to become the NHS that's fully block-funded. What the last term of government also introduced was the My Medicare reforms, and which is for the first time an opportunity for patients to select their usual, enrol with their usual general practice, their usual doctor.
00:13:21
Speaker
And that's a really critical reform and it's probably one of the most significant things that the last term of government did because unless you've got enrolment, you don't have a defined patient population. And if we really want to empower practices to know who their patients are and deliver the care at that kind of population level and elevate with appropriate funding to be able to do that care, then we needed the enrolment.
00:13:44
Speaker
So in terms of the block stuff, that's where, you know, we will need... and incentives and payments and and for practices to take on that extra work uh in terms of the restructure of the mbs items you're right now i'm unlucky we've got to have conversations ahead of how do you translate what was a really significant election ask election give uh you the budget investments into general practice um that are a fixed um incentive on top of an underfunded mbs
00:14:15
Speaker
if you re, yeah, the that's when the the accountants and the economists come into play in terms of, well, depending on how you shuffle the numbers, um where do the incentives add enough funding?
00:14:28
Speaker
the The key need is for some restructure because at the moment, even if you topped up all of your Medicare items, you would still have a disincentive for your longer consultations. So you do in fact need a structural change and then it's sort of a separate question to then go, okay, well also what's the funding that's required at each interval?
00:14:48
Speaker
um And yes, I'm sure there are, you know, it's time for negotiation. We've always got to be sensible about these things and we don't want to, we wouldn't do large scale cuts that are going to leave general practice and patients worse off.
00:14:58
Speaker
um But we've got to be clever about where are there opportunities to redirect some of the funding that's been announced. I've got to say that that's an incredibly insightful explanation of things and and all I could think of was is is really to... my One of my favourite movies is Karate Kid and there's Mr Miyagi and the need for balance and all this and balance.
00:15:19
Speaker
I think that that you know that you really are having to try and um tread the line between really complex issues and trying to balance the the the costings and incentives to get the the right um recipe to get the result we need, which is support for general practice to provide the right care for our patients of the future. which and I think you have a great insight into this.
00:15:43
Speaker
So, Danny, workforce is a big issue in general practice. ah Could you take us through what the AMA is proposing and what has already been agreed by government that we can look forward to in near future?
00:15:55
Speaker
Yeah, we are, we've got, be no surprise to anyone listening that we do have a shortage of GPs out there and our data and the RACGP data and Department of Health's own data all show that we're short of GPs um and ours says sort of to the order of about 10,600 GPs over the next five or six years um So we do need more GPs and we need them to work right across our country, including in rural and remote Australia.
Addressing the GP Shortage and Training Needs
00:16:23
Speaker
ah To get there, we did put to government that we needed more general practice training positions, but that we also needed more exposure to general practice in those pre-vocational years. And that was to combat some of the hidden curriculum of...
00:16:38
Speaker
you know once you're in medical school and through your pre-voc years you tend to be pretty hospital centric and general practice is that world outside the hospital that you're not really sure of someone may end up there one day but no one ever really talks to you about it and you just get sucked into the hospital machine and so we were really keen to make sure that more junior doctors more medical students more of those um pre-vocational trainees have an opportunity to try before you buy and to enter general practice on a rotation.
00:17:06
Speaker
Having said that, that our general practice registrars also often face a pay cut and a cut in benefits when they move from a hospital training position into general practice where there's no parental leave, study leave um and and a number of other entitlements. So we did push hard for um a few years on paid parental leave, study leave and equity of paying conditions. as well as those expanded training places and and I'm very excited that we did get that yeah out of the budget and election.
00:17:36
Speaker
um The government did pull that page out of our advocacy book and delivered all of our asks on general practice training and and so that will stem the tide of um the workforce shortage. It's important to recognise that GP registrars are providing a service from day one of their training, unlike some other positions where um they're you know part of a big hospital team. Actually in general practice, you're in a private practice seeing patients from day one and you're an additional um yeah workforce provider.
00:18:08
Speaker
So I think that we're heading in the right direction. Obviously in general practice we also need to think about broader workforces. There's been a lot of talk about scope of practice in primary care recently, um whether it's pharmacy prescribing, nurse practitioners, assistants in sort of physicians associates, and ah expanded scope for other allied health workers. There's a real fear in general practice of what that means for everyone's role and who's accountable and how this all coordinates to deliver the health system that makes sense for patients and not more fragmentation of care. And so for that, we've really kept talking about patient-centred, GP-led medical homes and multidisciplinary care.
00:18:51
Speaker
And to do that in general practice, we do need some block funding to be able to hire more nurses, more allied health, and really build those teams inside our practices and so that when we've got patients with diabetes or heart failure or chronic lung disease or mental health issues and they might need a social worker or a psychologist, we can build those teams in our practice using MyMedicare to know what our population looks like, have the allied health that we need on whether it's a sessional basis or permanent if we actually have enough work for them um and and build that cohesive structure
00:19:26
Speaker
that helps the GPs focus on the work that we're best at, but have that supporting team to really deliver the best possible care to patients without them having to retell their story 50,000 times and go to a bunch of different appointments that are all really hard to navigate and are cost prohibitive as well. So that's the bit we haven't quite nailed yet on workforce, but where we're really still pushing.
00:19:46
Speaker
Danny, can i just ask you ah question about politics now? You've got a minister who's a a very smart guy, he's got long history in health and has been chairing, I think, the Strengthening Medicare Task Force.
00:19:58
Speaker
So he's very aware of what is needed in general practice and of the variety of views throughout the sector. um And yet the commitments are stronger belt billing incentives to drive belt billing rather than better quality general practice. It doesn't quite connect. and And similarly, I guess, with urgent care centres, which were you know a linchpin of the election campaign last time and then again the most recent election campaign,
00:20:20
Speaker
lot of enthusiasm from
Effectiveness of Urgent Care Centres
00:20:22
Speaker
government. They believe they're on a ah vote winner with the urgent care centres and yet there's a lot of scepticism within the public hospital sector and within general practice about whether this is a reasonable investment of public ah funds, whether it reduces the pressure on EDs or not, and of course what it is doing to general practice.
00:20:41
Speaker
So how do you deal way with that, the the disconnect I guess between policy and what actually comes out um in in government. And could I quote some of my colleagues? Their their response would be boo.
00:20:54
Speaker
and And honestly, their their sense that really shows the data that this money is well well wellp spent and actually makes a difference. i'm with you on urgent care centres and I know that that was a really hot topic during your term um and in fact, ah you know, it was it made it really tricky for a while, the relationship between government and the AMA on urgent care centres, but the early reports of that are showing that they're expensive compared to general practice and yes, they may be a bit cheaper than an ED ah visit, but I'm yet to really understand, seems to be, depending on which day you ask, whether urgent care centres are an ED avoidance.
00:21:34
Speaker
mechanism or a GP access mechanism and they seem to be trying to fit both things so we're really ah working with the monitoring and evaluation process of the urgent care centres to get them to clarify that and really articulate what it is do they hope to be getting out of it and then what are you doing in terms of monitoring of that to show that that's what you're delivering um Certainly in my area, it' I've heard a patient describe it as just another place to wait.
00:22:00
Speaker
um And, you there's is awful stories of people turning up and waiting hours only for it to close its doors because they're not a 24-7 service. um And then they come to us the next day.
00:22:11
Speaker
Anyway, um but I think, you know Minister Butler really does understand health. As you said, he's deeply interested and dedicated to health. He did chair the Strengthening Medicare Task Force, which is unusual for a minister, I think, for people who haven't dealt with politics before to have had, in the end, it was probably about 10 whole days of minister time, at least.
00:22:36
Speaker
um That's unheard of. You know, a standard meeting with a minister is a half an hour if if and when you can get them to fit in. As um the AMA, we're pretty lucky we get the minister roughly monthly.
00:22:47
Speaker
But for many groups, you know, a half hour meeting every year or two is is a ah lot of minister time. So to get 10 days is just um a big commitment. And he does care. But then I think we have to remember there is politics in this and votes.
00:23:02
Speaker
um and the Labor government feels strongly about universal care and free ah you access to care without an out-of-pocket cost. um But now that they've delivered a couple of those things, you know, they've got urgent care centres, they've made this commitment about bulk billing,
00:23:17
Speaker
Surely now with the wins they've had and the security that they should be feeling in Parliament, now is the time to drive reforms. yeah Use that win to really deliver some healthcare reforms that will help Australia's healthcare system stand up to another 40 years of of health challenges.
00:23:35
Speaker
um So that's what we'll be encouraging them to do is yeah they've bought themselves the safety net, they've got that security, now let's get that um that reform happening.
Importance of Data Quality in Healthcare Funding
00:23:46
Speaker
we just talk a little bit about the one of the elements of um the AMA's modern modernised betterset Medicare campaign, which is ah you know increasing data quality about what happens in general practice?
00:23:59
Speaker
And I think, you know, look, I'll all sort of sit set it up that, you know, I think there's there's always been um several concerns from general practice. We used to have the beach data set, which was that sort of pamphlet you have to fill out about what you did during a day.
00:24:12
Speaker
I think there was actually some resentment from general practice because there there was a key item number, especially associated with mental health, which was reduced. it it It was ah reported as a result of the the the reporting backed by GPs through Beach.
00:24:28
Speaker
um And also, i think there's always been the concern about the amount of work um that's required for data. But the flip side of that is, there' an ah ah I mean, having been in an advocacy position like self-care,
00:24:40
Speaker
Before, um you know, a lot of my colleagues will say on the one hand, look, ah we're doing so much for our patients and I know that and we need more funding for this. And if I her go to the the minister or, you know, the department, I'll say, well, we're doing all this. Give us, you know, give us some more funding because we do so much good. And they'll say, show us the data and we can't.
00:25:02
Speaker
And we're in that terrible dilemma where we, you know, there's some negativity about data, but then also we we absolutely cannot compare data quality compared to hospitals, for example, who rely on data to actually show what they do and and can, to a much greater degree, prove, you know, ah potential effectiveness of their interventions. I think we've got to accept data is king and funding often follows data, and but we also need to to catch up with the modern age. General practice, actually, to give them some credit, have been really good at keeping up with digital health initiatives. They were one of the first of our specialties to do
00:25:41
Speaker
digitized patient records on mass and we've all had an electronic medical record in general practice for longer than our public hospitals our private hospitals and our private specialist practices like so GPs have led the way um but we're still in some ways rec recreating a paper system electronically and beach was an example of that where the the deep data collection was really manual and even now a lot of our coding for things like reason for visit or um information that might be helpful to boost funding all has to be manually put into a system
00:26:18
Speaker
That's not a very sensible way to do stuff in 2025. Like, come on. so But we do need to be able as a system to better articulate what happens inside a general practice consultation. What is it that takes 25 minutes instead of six minutes that really is delivering value and health care to the consumer? What is it about that extra 20 minutes that keeps them out of hospital? And we've got to find smart ways of having our systems report that back in a safe and secure way. Like obviously the underlying principles here need to be patient um you confidentiality and those principles that we stand by. But we what we can't do is require GPs to tick a bunch more boxes.
00:27:03
Speaker
ah to share data, but we do need to find ways to extract that safely from our systems to be able to drive that funding improvement.
Conclusion and Listener Engagement
00:27:13
Speaker
I think we're out of time, Danielle. We could talk about general practice policy for hours, of course, but I think we've probably reached the end of our listeners' tolerance for hearing our voices.
00:27:26
Speaker
It's very clear, though, that the AMA is deeply involved in advocacy on general practice issues, which I'm sure our GP members will be pleased to have heard a little bit about, have bit of a deep dive into some of this stuff.
00:27:38
Speaker
And, of course, we're hoping that soon we will have um the ability for listeners to ask questions so um of our um ah guests here on the podcast and and of Chris and I as well.
00:27:51
Speaker
ah So thank you again, ah Danny, for joining us again on our second episode. And to our listeners, thank you also for joining us. If you want to learn more, visit ama.com.au and check out the AMA's full submissions on general practice issues. And don't forget to subscribe and share The Waiting Room. We'll be back soon with more conversations that hopefully enlighten you.
00:28:12
Speaker
Thanks for listening to The Waiting Room.
00:28:16
Speaker
Learn more about the AMA, including how to become a member, ama.com.au. dot a