Entries categorized as ‘Medicare & Government’
Changes to Primary Health Care delivery
Once again the Federal Govt has excelled itself in red tape. what it is trying to achieve is a reduction in what is termed “avoidable hospital admissions”
I would suspect that they really have not looked at these cases but only went on anecdotal evidence. The idea was that GP’s do not really look after patients when it all gets too hard, but slough them off to the Hospital Even more so after hours. The reality is that there are more and more frail sick people with multiple problems for which there comes a time when the GP can no longer manage them in an ambulatory clinic situation. House calls are a part answer, but it is not cost effective.
So in an effort to manage the patients “better” it is proposed that they be more closely managed by a single clinic. Of course it will change nothing. The end point will still come and referral to a hospital will still happen to them. CMA / Team Care was tried and it has made no differerence. They were never followed up They just sit in the notes and never refer to them.
The question is how will the patients understand that the “package of care” is supposed to effect a measured change. It is just Fund Holding by stealth. But what happens when they present for as sore throat separate from this package. You charge!! So what is to stop getting the package and then charging still ?
Again what happens when the patients do not present for their supposed check ups / monitoring. Patients do not care about it all they just want instant health care for free. No responsibility for their actions. To properly manage this you need a database that keeps track of where each patient is up to and what is needed. But do we contact them when they are overdue? No I do not think so. When they come in for a consult (usually unrelated to chronic disease) then you need a quick reference that says that this and this needs to be done. Then do it eg you need cholesterol levels done….
What I as a locum need to do is to make sure that I have solid management plans for the various problems I will encounter. To apply them to various patients at the time of consult eg need BP check / need cholesterols
It is up to the clinics to advise how they want me to manage the new “packages of care” but I suspect that things have gone too far and we will just keep on consulting as we have always done because it will be too expensive to construct an alternative model of consultations using a database of exception reporting.
What then should be done is to just make sure we manage our patients to the best of our ability
Categories: Medicare & Government · Patient Care
Why blog at all?? I think it is important to record my ideas, thoughts and comments as well my forecasts about General Practice. In this way I can record where I think things are headed. More importantly what actions I should take to align myself with what I see as the future. I have done this all my professional life. It is not second guessing.
But at the moment all I can discern are changes to registration which involves revalidation and comments on cognition tests for doctors.
There are no changes to basic consulting patterns – no new ideas!! So what is this telling us.
I believe that Nicola Roxon is just a public servant with a few new ideas but her kite flying evoked the wrong response. She realises that if allied health is to do any Medicare paid work then there will be an additional cost. there will be no cost savings. Also GP’s will not back or support independant groups. So they function alone and wear the medico-legal challenge. It is no use thinking that the existing nurses working in doctors rooms will do any additional work. Their sessions are always full. There is no more room for any more nurses.
So what would be the result of any mandated changes..eg paid less for driving licenec medicals. Doctors would still do them and the gap would be more. Consult pattern will not change.
Care plans have not altered patient outcomes. They are done in addition to the normal consultation patterns. I have written on this before. So where does all this leave us. With all this indecision it means that the AMA has got its act together and has formulated solid proposals and highlighted problems. Now all Nicola can do is to play catch-up. If she attempts to go against the AMA proposals then her plans will end up in a mess with patients having to pay more.
The major challenge in GP work is to integrate any followup plan in a normal 15 min consult. If you attempt to move to a special number then you are monitored (see what has happened with level C&D consults)
Another challenge is to ensure that we have concise investigation plans for various diseases easily available so we can initiate investigations before referrals.
Categories: Medicare & Government · Uncategorized
Tagged: GP Clinics
Nicola is right!!
Her assessment that others can do the job that GP’s do and just as well as the GP is correct. Sacrilege I know but when you look at what the average suburban GP does each day it is not really that difficult. When the difficulty level rises then referrals are necessary.
For such a GP the average day is episodic care for people who have aches and pains, feelings of unwellness – all of whom need blood tests, x-rays and ultrasounds all of which will be negative. Then there are the “check-ups” BP’s, lipids arthritis etc. Not very complex skill level here needed. Repeat pill scripts and cervical smears are usually the lot of the female practitioners. Asthma now needs complex investigations while stable diabetes means more of the same. If changes then off to the diabetic specialist.
PLUS the forms to complete ranging from Workcover, drivers licence and Centrelink. This is the average day.
There are no emergencies to worry about in the metropolitan area as much we try and fool ourselves to maintain some relevance. The reality is that serious problems go by ambulance to the A+E dept. Nursing home visits (if done) are also not complex as the nursing staff do most of the work.
In short if you dare to take on palliative care or manage some cardiac problem then you quick smart get reprimanded by the specialists in those areas. This is the same for any problem you might have identified. E.g. prolactinemia or PCOS …off to the specialists.
Why then have we become so dumbed down??
It is a combination of the need for short consults in order to make a decent living and run a practice – plus the medico-legal implications of mal-management (especially in the metro area) So we go on saying that only we as GP’s can do it. Slowly but surely our diagnostic skill levels drop (we do not need them). We just need a good network of specialists to whom we can refer/.
We go through the charade of CDM + TCM plans because they generate money, but we know that in order to make a difference follow-up is needed but it can never be properly done. So on we go as metropolitan GP’s.
As you can see Nicola is right . it does need a highly trained person to do the job of a metro GP.
This is precisely why you will not get GP’s into rural areas where the skills required are enormous. But no more than used to be demanded of metro GP’s in past times. We still cling to these outmoded images. Why shift to the country when we can make a living in the metro area without a lot of stress and the deprivations of country life.
All of this is very sad and depressing but this is the way that the govt and social pressures have shaped us. Most of us keep seeing patients because we like that type of contact and this is why we get upset when Nicola wants us to tackle CDM by a coordinated team approach which means more paperwork and less patient contact. If we want to be true medical professionals then we should do rural medicine or become a specialist. This is probably the reason why there is a rise in GP sub-specialisation.
Change is coming. The tidal wave of chronic disease management is here.
So in summary
Until the govt educates the patients about their part in health management we will just keep on being metro GP’s without any high expectations of patient management but avoiding being responsible for the actions of other health professionals around us. It is time to move on when we wake up in the morning and believe what I have just written and believe that what we do will not make the slightest difference to any patient.
Categories: Medicare & Government
GP Super Clinics and other GP workforce issues
Just some ideas and thoughts about these issues
14 of the 32 Clinics are going to be in places where GP’s are in reasonable supply. They have to be established there so as to attract doctors to work in these “super” clinics. That is where the doctors will come from These clinics will compete with local GP’s and such GP’s will be forced to join to survive. That will be a good start to get a group of caring GP’s.
The policy framework of these Clinics will have to lay down After Hours / Home / Nursing Home visits or else there will be a lot of flak. Probably be in the “tender” documents. What will happen is that they will charge a lot for such visits or giving it to Locum Services. There will essentially be no difference to a Corporate set up because the govt will not want to continually prop up such clinics.
Training of GP’s will be part of the set up and more training $ will be paid to get this going and so lessen the need for smaller clinics to employ such registrars. These training places will be like the hospitals when they train surgeons / physicians. Govt money will flow to make sure such training will happen. If the clinics appear to be failing then money will flow in to support them.
So the metro market will settle down with these centres focussed on training.
The fact that they will be expected to bulk bill also means that people will tend to go to these clinics. Also this fits with a report that this is the style of practice the under 25’s want. This episodic approach by patients plus the increasing supply of doctors will downgrade GP work. Eventually there will be too many metro GP’s. They will not be driven into the country because 70+% will be female. Anyway why do rural work with the added rural layer of problems such as Hospital work and emergency work without a lot more money to compensate?. Why relocate? Instead niche practices will spring up such as skin , asthma and diabetes.
Even if a 2 year contract offered to relocate to a rural area because then you have to return to what…? So instead get into a metro practice keep your head down and work 9-5. This might be alright for a female but not a male doctor. So what will happen. He will just settle in and do his job and make $. He will not complain unless there is more money to make. He will develop a life outside medicine such as real estate development or shares. He will just do the bare minimum in the Practice and chronic disease management will suffer. He will become self and not practice orientated. Medicine will just be a job to make money. He will be very compliant and do whatever the govt wants. But if it gets very hard he will leave medicine.
This behaviour will be reinforced by the big clinic’s approach to these doctors.
It does not that there will be much interest in chronic disease management unless the clinic organises it. It is a bleak picture but a realistic one by a group of disaffected professionals unable to move outside defined practice guidelines dictated by governments.
Trebor
Categories: Medicare & Government
Tagged: GP Super Clinics
I cannot understand why people are excited about a “series of explicit targets” especially Paul Smith in the 16/5/08 issue of Australian Doctor. “Why shouldn’t GP’s get involved?” WE ARE INVOLVED!! I fear it will be just one more thing that will be forced on GP’s. There will come a time that i have spoken about before where doctors will be forced to choose between being a caring flexible doctor vs being someone focussed on his / her future in order to survive. Gradually gradually our discretionary management options are being eroded. This new federal govts insistence on performance targets will back fire.
How can the govt be responsible for making sure a proportion of asthma patients have action plans or that type 1 diabetics must have hb1ac <7…unless the govt is going to take over their management. What will happen is that somehow GP’s will be forced to achieve these goals with all the attendant red tape. How ?? well by tying it into the PIP paymemts. But what about those practices not accredited., They will have to be accredited or get less per consult in an unaccredited parctice. This is the recommendation of the Reform Commission.
Interesting days ahead as small practices will have to fold and just walk away; perhaps to join the Mega Clinics
Categories: Medicare & Government
Tagged: Control of health
