By Dr Joe Kosterich
Many years ago, I did a share trading course based on the work of William Gann, reputed to be the most successful Wall Street trader ever.
His approach was to study past cycles to predict future ones. He contended that like crops and the seasons, everything in the universe has a repeating cycle.
For the record, I have not made a fortune as a trader. However, I find his concept of history repeating in cycles applies where you least expect it — including general practice.
The latest evidence of this is the MBS review of care plans.
Like accreditation, divisions and most recently after-hours care, a cycle repeats itself. It begins with government unilaterally introducing change sought neither by GPs nor patients. Initially GPs are wary, and few sign up.
To address this, government introduces incentives to make it more appealing. A trickle of GPs becomes a flood and ultimately the budget blows out. At this point in the cycle, government clamps down to rein in the spending.
For example, the changes to after-hours care in 2012 were designed to increase the number of out-of-hours visits. It worked so well that last year, changes were made to contain the cost blowout. And, of course, GPs were blamed.
Since the days of Hippocrates, there has been a GP management plan. It was drawn up with the patient, but not documented to the requirements laid down by civil servants in Canberra.
When care plan items were introduced in the early 2000s, many GPs refused to do them. However, eventually the trickle became a flood, and now the government wants to rein in expenditure.
Let’s be clear: care plans themselves do not alter or improve clinical outcomes. They are a bureaucratic tool to document what GPs have always done, a bureaucratic requirement for access to allied health services.
They have served as a roundabout way of providing more dollars for general practice without increasing the rebates for consultation items.
The current thought bubble from the MBS Review Taskforce’s general practice and primary care committee is to set a 40-minute minimum for drawing up care plans.
Developing a plan for a patient you have never seen (which is not supposed to happen) should take at least 40 minutes.
But most are written for established patients, where the GP has considerable ‘corporate knowledge’ of the patient, even if not everything has been recorded.
In this scenario, time borders on irrelevant. Some may take 40 minutes or more due to the need for significant changes. Others may need only 15 minutes as all that is being done is the ticking of boxes for care already happening.
Therein lies the real problem — the culture clash of government, which is focused on process regardless of outcome, and general practice, which is focused on outcome and not fussed about process.
Further, GPs know that no two people are identical and thus identical process will never lead to identical outcomes.
GPs understand that people have conflicting priorities and health is not always the top one.
The agenda here is not about care plans or quality care. It’s about saving money.
Thus, we can expect the end result of the MBS review to be some reduction in payment. Governments (of either persuasion) know that GPs will continue to do their best for their patients regardless and thus know that, despite some bleating, we are price takers.
The underlying issue is that since 2008, Australia has had massive debt, but still spends like the proverbial drunken sailor.
And as long as bulk-billing rates remain the only indicator of Medicare’s success, governments will continue to promise ‘free’ (paid by the taxpayer) GP visits, even though it is unable to properly pay for them.
If we understand that, we might find a genuine solution. One has been floated by RACGP president Dr Harry Nespolon — a co-payment at the point of service.
This exists in every other form of insurance, including private health, and would enable GPs to receive proper remuneration, governments to control outlays and patients to contribute a fair amount.
With this in place, care plan items would become irrelevant.
Even before care plans were introduced (and in the future, when they inevitably disappear), quality care for patients has stayed the same. Only the paperwork requirements change.
The Health Care Homes model now being pushed by virtually every GP policy wonk is the start of the next cycle.
I know what Gann would have predicted.
Dr Kosterich is a GP practising in Perth.
