incentives in australian primary medical care

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

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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

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• 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

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• 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

• 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


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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

Patient coverage of Participating Practices

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Change in name from BPP to PIP

Transition payment

First payment under new arrangements

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• 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

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• 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

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• 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)

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• 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


• 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)

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Commencement of incentives

Immunisation rates

Start of GPII

0

10

20

30

40

50

60

70

80

90

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Year

Nu

mb

er

no

tifi

ed

Start of GPII

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Notifications of mumps, Australia, 1991 to April 2002, by date of onset

[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

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Use of Computers

Tier 1 - Providing program data to Government

$3.00

per SWPE

Tier 2 - Use of prescribing software to generate majority of scripts in the practice

$2.00

per SWPE

Tier 3 - On site use of computer/s and modem to send and/or receive clinical information

$2.00

per SWPE

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

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Aug-99 Nov-99 Feb-00 May-00 Aug-00 Nov-00 Feb-01 May-01 Aug-01 Nov-01 Feb-02

Payment quarter

Per

cent

age

Pat

ient

s co

vera

ge

Electronic prescribing

Data connectivity

Tightened guidelines

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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 multi-disciplinary 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

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Care Plans per quarter

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

1999Q4 2000Q2 2000Q4 2001Q2 2001Q4 2002Q2 2002Q4 2003Q2 2003Q4

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

incentives in australian primary medical care

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