The most appropriate response to the Strengthening Medicare Taskforce report is a “meh” and a slow clap. Heavy on motherhood statements and light on detail (or how and when the detail will be provided), the report is remarkable only for its lack of imagination — and for studiously avoiding two important ways to strengthen Medicare.
It’s not that the content is bad or ill-conceived; it’s that it mostly restates what people have been saying for a decade or more. We know the “what”. We need to flesh out the “how”. In terms of genuine reform, the report hasn’t really advanced our thinking about how to build a healthcare system for the 21st century. There aren’t many new ideas in it.
The lack of imagination is hardly surprising. From the start, the taskforce was dominated by healthcare providers for whom the status quo, while not perfect, is certainly preferable to actual reform that puts the interests of the patient, public and taxpayer first.
For example: “Strengthen funding to support more affordable care, ensuring Australians on low incomes can access primary care at no or low cost.” Well, yes. Of course. Who would disagree? But how about ideas on how to achieve it?
The document contains a few good policy kernels. “Sharing [data] by default” across different providers is a sensible way to make care safer, more integrated and efficient. (Doing this may seem like a no-brainer, but it’s amazing how slow the healthcare system has been to ensure people’s information follows them as they seek care across the system.) It’s good to see patient registration mentioned as another way to improve care continuity and outcomes.
It’s also good to read about comparative feedback to providers about their practice (it would have been even better to see the systematic collection of patient-reported measures mentioned) and the document is right to acknowledges the excellent results of Aboriginal community-controlled health services — a model that would be a good fit for mainstream primary care (as I’ve previously argued).
But elsewhere it is completely out of tune with current thinking. Take the first recommendation on improving access: “Support general practice in management of complex chronic disease through blended funding models integrated with fee-for-service…” (my emphasis). There is almost universal agreement in health policy circles that fee-for-service is a relic, ill-suited for modern health challenges. It promotes volume, not value (to patients and taxpayers, that is).
The report has this to say about fee-for-service: “Our primary care system funding mechanisms reward episodic care and fast throughput.” To imply that instead of phasing it out, new payment models will be integrated with it seems rather odd — if not insincere.
The other flaw, however, is what it doesn’t mention. Two important omissions struck me as very strange. The first is taking pressure off health services through better social care, a lack of which results in declining health, especially the sickest and most vulnerable. The result is greater demand on primary and hospital care (and delay their discharge generating bed shortages and ambulance ramping).
Housing, for example, has been shown to reduce demand on health services. Sure, it’s not in the health portfolio, but isn’t silo-thinking part of the reason we need a taskforce (and one of the things it is trying to fix)?
The second omission are private medical specialist services, which make up about a third of Medicare expenditure (yes, a large chunk of “private” healthcare in Australia is taxpayer-funded — through Medicare and the private health insurance rebate). Yet a considerable proportion of these specialist services (tests, imaging, procedures) are unnecessary. It’s inconceivable that an attempt to strengthen Medicare avoids discussing how this waste can be reduced — if not for any other reason than creating more fiscal space for primary care.
But every dollar of expenditure is a dollar of income, and while the doctors’ union, the Australian Medical Association (AMA), may be outwardly critical of the report, in private it will be pleased that (a) medical specialties escaped scrutiny and (b) the scope of the report excludes any suggestion that non-medical factors may play an important role in strengthening Medicare.
Only a brave politician takes on the medical establishment, especially on income. Just ask Nicola Roxon, Nye Bevan … or the government of South Korea circa 2000, where doctors went on strike over a proposed law to prevent them prescribing and dispensing medications (resulting in the loss of a lucrative income stream).
If this government really is fair dinkum about reform, the next instalment of Strengthening Medicare needs to provide a detailed policy framework informed by a panel that is less weighted to commercial interests and more towards those who use, and pay for, the scheme. Otherwise the whole exercise will be another wasted opportunity.
