When travelling you always come across new terms and phrases. In Canada, they refer to the Emergency Department as “emerge”. When you couple this novel term with the Canadian accent it is always amusing to be told a patient was sent to “emerge”. Fortunately, they have good data on how many patients emerge after a visit to ED and proactively work at primary care level to stem the tide.
Beyond cute names, what has emerged in New Zealand, Canada and whilst visiting New York State is the focus on disadvantaged groups. Australia likes to pride itself on batting for the underdog. Sadly, when it comes to healthcare, even the Americans are starting to leap ahead when it comes to funding comprehensive care for the battlers.
America has had Medicaid for decades. This funding targets those patients who do not have insurance, which is generally employer sponsored, to cover their healthcare costs. The Adirondack region we visited in upstate New York contains six counties which are exceptionally poor farming areas. The State of New York identifies patients who qualify for Medicaid assistance and provides incentives to providers to locate them, maintain monthly contact and build case management and care teams around them. This coordinated care is delivered by case managers housed within medical centres. They liaise with health and social welfare providers to build a patchwork of support around the patient. Applying new case management funding, they have worked with the 28% of their population who meet the criteria and delivered. For example, they have driven down the 20% hospital re-admission rate within 30 days to 12%. They have also made savings in the cost of care of around $20 per patient per month within their capitation envelope. When you consider their region has shy of 300,000 people, with over one quarter being severely disadvantaged, the multiples soon mount up.
In Canada, Health Links is funded for the top 5% of hospital users to try and contain their care in the community. Business cases can also be mounted by medical centres, based on population modelling, to secure additional allied health in areas where chronic disease and disadvantage are high. Community Health Centres receive dedicated funding to support the homeless, refugees and those with recurrent mental illness. All of the doctors in Community Health Centres are salaried to reduce the incentive to push patients through.
New Zealand shares this approach, funding Community Health Centres to support the needs of the most disadvantaged. In addition, the capitation model takes account of regional health and demographic profiles. General medical centres are paid more for the percentage of patients on low incomes or with multi-morbidities to reflect the increased demand such patients bring.
In Australia, we have special funding for indigenous groups who clearly face significant health issues. However, we have no equivalent of Community Health Centres outside of the Aboriginal Medical Centre stream. We have no additional sources of funding beyond the same Medicare time based rebate which applies in catchments full of “worried well”. In disadvantaged catchments, where bulk billing is the only game in town, the business model is heavily skewed towards six minute medicine. This is precisely the sort of model which does not serve such communities. In fact, it hurts the rest of the tax paying base as these same patients are likely to need to come back time and again to deal with their complex array of diseases. It would be cheaper to simply fund longer consultations which reflect the complexity of care involved in managing these patients rather than have them return or be referred to hospital.
So what emerged from my study tour so far is that when it comes to health care, the Australian ideal of a fair go is not reflected in our health system. Other countries are way ahead of our batting average in dealing with the social determinants of health. We have no choice but to stay in this game as from 2016 more than half of all general practice consultations will be with the multi-morbid. In catchments with the double whammy of poverty and ageing, appropriately funded integrated care teams will deliver better results than our current one size fits all Medicare funding. Australia, it is time for the battlers to get the help they need so that you have a hospital bed or short wait in emerge the next time you need it!
Tracey Johnson, General Manager, Inala Primary Care