Australia spends just 6% of the total Medicare pool on primary care. We also know that 4% of our population use 40% of Medicare services. So what would happen if we doubled the allocation of funding to primary care? Would it drive down the overall cost of supporting these high intensity users?
America is home to a rapidly growing healthcare group called Iora. The owner was identified by one of my heroes, Atul Gwande as a healthcare innovator to watch in 2010. We need to start watching!
Iora Health began by taking over the care of union members involved in the Las Vagas Casino industry. Iora demanded that 10% of the insurance budget was allocated to primary care. In America, primary care generally costs insurers around 5% of their total spend, not too dissimilar to the Australian slice.
Iora runs all of its primary care in community settings rather than through primary care facilities attached to hospitals, delivering more accessible care with savings funneled into service augmentation. It has also delivered. The gambling union achieved over a 30% reduction in the cost of caring for its members.
Iora has now partnered with another insurer focused on Medicare patients (these are always over the age of 65 in the American context). Given these folks are almost always on at least one medication and likely to have a minimum of two or more chronic conditions, they are a comparatively high need group. Iora has applied the same logic and demanded 10% of the insurer spend for primary care. In exchange they have so far built 8 primary care facilities with another 18 to come online by January.
Rather than public health style facilities with lino and vinyl furniture accompanied by advertisements for incontinence and hearing aids, the reception area resembles a home lounge and cafe. There is no reception desk. Instead, arrivals chat with a team member around a dining table or even in their comfy chairs. The receptionist has a wireless laptop and mobile phone and is tasked with engaging the patients. No uniforms are provided and everyone is on the care team.
Every patient spends a minimum of 45 minutes each visit with a Health Coach before they get to see a doctor. The Health Coach takes vital signs, checks on referrals, determines if scripts have been filled, identifies eligibility for any screening tests, looks for changes in patient circumstance and takes a depression and anxiety score. Other time is allocated to dietary education, advice on exercise and socialisation and checking in on achievement of health goals. The doctor then spends up to half an hour with each patient.
This is intensive, team based medicine supported by a morning huddle. This lasts for one hour, much longer the the equivalent huddles I have seen in other countries and jurisdictions. All of the facility staff meet to discuss their own readiness for the day, patient progress, those who have been hospitalised and those who continue to be of concern in addition to the roles they will play with the patients scheduled for the day. They also celebrate victories and share dashboard detail to round out the session.
The results? Well, they have the money to keep expanding, are being featured in journals across the nation and have queues of people wanting to work for them. Their efforts are provoking huge debate about the culture and process of healthcare in America. Intuitively, their model makes sense. It also brings service into the heart of care, a sure winner with voters conditioned to expect service in every other aspect of their lives. However, it changes the doctor patient bond to a team of care and bridges the social and medical divide in new ways. If we accept that patient centred care dramatically improves patient engagement with their health and equips them to self-manage, this would seem like a cost effective way forward.
Tracey Johnson, General Manager, Inala Primary Care