How much money will it take to fix general practice? The promised funding boost of $250M for general practice is not going to be enough. I know that sounds ungrateful but $250M is about $10 per Australian per year. If the new funding is spread across all GP Medicare rebates, then each rebate will increase by about $1 each. To quote Amanda Vanstone, this is a milk shake and a sandwich.
First of all, why do we need to spend more money to fix general practice? The rapid recap is that 84% of Australians see a GP at least once per year, and of all the medical specialties has the greatest impact in keeping Australians healthier. For example, the most reliable predictor of whether a person with diabetes will be admitted to hospital in the next 2 years is not how good or bad their glucose control is, but the strength of their relationship with their GP. A US study has estimated that for every $1 invested in primary care saves $13 of downstream costs. A recent Victoria University report, estimates the economic returns associated with funding preventive health initiatives in CVD and diabetes generates around $12.75 for every $1.40 spent. To put it simply; GP’s reduce the overall cost of care and reduce hospital admissions.
Every country needs to maintain an optimal mix between specialty medical care and GP care. Many of the narrower specialties have demonstrated some potentially negative impacts on health, so getting the balance right matters. In Australia the mix has been steadily shifting to more specialists and less GPs. GPs used to make of 50% of the medical workforce and they currently make up about 29% of the total doctor workforce by headcount, and this is likely to fall further with only 15% of final year Australian medical students indicating they intend to undertake a career in general practice. The irony here is that General practice, is the type of care the public want. The public want to be managed in the community, and they would like to avoid spending time in hospital.
There is reasonable evidence for the statement that general practice is the “cornerstone of our health system” as per Greg Hunt and Anthony Albanese. But how much funding does general practice receive? The answer is 6.8% of the total health spend or about $12.6B in 2017/18. Another way of framing this is where 29% of the medical practitioner’s work receive 6.8% of the healthcare spend. Clearly general practice is not funded like the “cornerstone of our health system”.
How much should we optimally spend on general practice? The Royal Australian College of General Practice has proposed a tripling of the bulk billing incentive rebate, and they estimate this will cost $1.4B per year. The current bulk billing incentives provide a rebate of between $6 and $9 depending how urban or rural you are. If the proposal is implemented, then the incentive increases to between $18 and $27. However, we need to be clear that this incentive is ONLY for people under 16 and people with health care cards who are bulked billed. So, this is a targeted proposal to encourage bulk billing of vulnerable Australians. This initiative (if implemented) will be effective in maintaining and improving access for the most needy and in the current high inflation environment will be welcomed.
The other key suggestion has been from the Strengthening Medicare Taskforce chaired by the Minister of Health, for blended payments. The Medicare Taskforce says we need to:
There is quite a bit to unpack in that one sentence and I am not going to attempt to do that. What I am going to say is if you want to avoid the Amanda Vanstone comment earlier, then the amount of additional funding for blended funding models will need to be meaningful and I assume this means between $2B and $3B, or about $100 per Australian per year. Not every Australian will be funded at $100 per annum, as the statement above suggests the funding will be weighted to vulnerable demographic groups and people with complex needs. For example, a patient with high needs may attract a blended payment of $200 and a patient with low needs may be funded at $40.
So, we have the RACGP proposed $1.4B for bulk billing incentives and lets say another $2.5B for blended payment models as per the stated intent from the Medicare Taskforce. An additional $3.9B of funding would take the total spend in general practice from $12.6B (2017/18) to about $16.5B, and if implemented should take general practice to about 9% of Australia’s total health spend.
Of course, this funding won’t be possible without general practice making some commitments for some deliverable outcomes. One outcome will be the formal enrolment of all patients in a specific GP practice. The deliverables will be an important discussion, but putting that to one side, is it reasonable to expect the “cornerstone of our health system” to survive and thrive on funding that is declining and now below 7%? And should GPs lobby for a commitment to target a health spend of 10% as being in the best interest of everyone?