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Thursday, December 07, 2006

The Government Has Absurdly Low Expectations for Practice Incentive Payments.

The Australian General Practice, Practice Incentive Program (PIP) has been in operation since 2001. In this program accredited General Practices are provided with financial incentives to reach various performance targets. The PIP grew out of the Better Practice Program in response to a series of recommendations made by the General Practice Strategy Review Group (GPSRG) that reported to the Government in March 1998.

Payments are made on the basis of a factor termed the Standardised Whole Patient Equivalent (SWPE) which is an estimate of the level of practice complexity and activity based on information gathered by Medicare Australia during its payment processing for Medicare funded services.

The typical General Practice will be about 800 – 1600 SWPEs per full time doctor – e.g. a 4 man practice will have a SWPE of about 4000. The statistically average FTE GP sees 1,000 SWPEs annually according to Medicare Australia.

The overall program is by no means trivial having cost $250+ Million in 2005/06.

One component of the PIP focuses on the deployment and use of Information Technology in General Practice.

The IM/IT PIP program used to cover three areas until it recently was updated – with different requirements for payment eligibility – in November, 2006.

In the earlier version the payments were as follows:

Tier 1 - Providing data to the Australian Government - $3.0 per SWPE

Tier 2 - Use of bona fide electronic prescribing software to generate the majority of scripts in the practice - $2.0 per SWPE

Tier 3 - The practice has on site and uses a computer/s connected to a modem to send and/or receive clinical information - $2.0 per SWPE

Thus to receive $7000 a year per practitioner a practice essentially had to fill in a few practice profile forms, utilise prescription printing software that could be obtained very cheaply or free from HCN Ltd and have a modem to pick up results electronically from a local pathology provider.

Given the economic life of a PC is about three years this amounts to a very substantial payment for a PC and a printer. Even if a networked environment for three to four practitioners was deployed $60,000 - $80,000 would be more than enough to fully fund the system, its installation and a considerable profit!

It should also be remembered that prescription printing – and most especially repeat prescription printing - is one GP computing function that has been demonstrated to save GPs time and thus money. Despite this we (the public) paid them to start using it!

Under the new payment scheme the criteria have been updated.

For Tier 1 the practice has to record electronically the allergies of a majority of their active patients and to have in place adequate internet and anti-virus security measures. This gets the first $4.0 per SWPE.

For Tier 2 the practice must record major diagnoses and current medications in the patient’s electronic record. This generates an addition $3.0 per SWPE.

On the basis that there are a little over 4000 practices are signed up for the IM/IT PIP payments, and that they have an average of three practitioners each, this is costing approximately $84 Million per annum. A non trivial sum I would suggest.

What is actually going on here is that the Government via Medicare Australia is paying GPs to undertake the most basic parts of electronic patient record keeping and setting the expectations so low that only minimal benefits are likely to flow.

Were there requirements to actually code diagnoses and medication so useful practice statistics could be generated and issues such as tracking ADE’s for newly introduced medicines could be undertaken there would possibly be some real value.

Additionally coding would enable basic clinical decision support relating diagnosis and treatment to be achieved – a major benefit.

Also it seems the software requirements of the present program could be, clumsily, met using a simple spreadsheet or database program with no ability to be improved and extended to deliver more benefit. That there is no requirement for certification of the functionality and safety of the software used by GPs to obtain PIP payments is appalling and a major policy failure.

For the money to be claimed there should be quality, functionally rich software supporting advanced clinical support insisted upon and used. Anything less is really risible.

As a concerned citizen I believe we should all expect more certainty of benefit for our GP computing money.

When we combine these funds with other Commonwealth funding of programs such as Broadband for Health (BfH), which is funded to as much as $40 Million per annum, as well as other smaller initiatives such as the Eastern Goldfield's Project, we really have the federal Government throwing a lot of money at GPs in an amazingly profligate fashion.

It seems to me, just as there is a need for strategic clarity from NEHTA, there is an equally strong case for the same from DoHA in terms of clear objectives and evaluation of the expenditure.

Simple, relatively inexpensive, proven to be effective, initiatives such as replicating the NSW Health Department’s Clinical Information Access Program (CIAP) nationally for GPs and specialists would be likely candidates for investment as would the sponsorship of the development of quality, certified clinical systems for clinical use.

I wonder, has a business case to justify all this spending ever been developed or has there ever been a retrospective review of the impact of the spending?

To quote Mr Abbott from a press release of December 2005 which was based on a speech entitled: Better records make better doctors

A speech by Minister for Health and Ageing, Tony Abbott, to the Australian Medical Association E-Health Forum, Canberra, 8 December 2005.

“Five years ago, the Health Ministers' Council first committed all Australian governments to the development of an integrated IT-based health record system. Over the past decade, the Commonwealth Government has paid some $600 million in IT-linked GP Practice Incentive Payments. Over the past 18 months, the government has committed $60 million to the Broadband for Health initiative, designed to ensure that every general practice and pharmacy has access to business-grade connectivity. So far, the government has committed more than $110 million to developing HealthConnect, including $9 million in half-funding the National Electronic Health Transition Authority which aims to standardise usage and facilitate inter-operability of federal, state and private health IT systems.”

See: http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health
-mediarel-yr2005-ta-abbsp081205.htm?OpenDocument&yr=2005&mth=12

This is almost $780 Million in all over the decade. I wonder what benefits we have really received for all this investment?

I am sure any other program of this scale would have to have been rigorously evaluated. Has anyone seen the report?

David.

5 comments:

zeeclor said...

"Were there requirements to actually code diagnoses and medication so useful practice statistics could be generated and issues such as tracking ADE’s for newly introduced medicines could be undertaken there would possibly be some real value."

While this may be true, it is a little tangential to aims of the government which are to setup the infrastructure for secure medical communication.

Coding and its derived benefits are undergoing trials in other government funded projects. However, the government faces stiff opposition from general practitioners in relation to their divulging data about both their practice statistics and their actual clinical practice.

I cannot see the PIP scheme as ever being a way of getting this sort of data.

Aus HIT Man said...

Hi Zeeclor,

I don't think that was the core of my case.

My case is unless data is coded real clinical decision support is not possible and thats where the real benefits for patients, Government and doctors is to be found!

We need systems that do all this properly - not the least the software industry can get away with - and we need to be certain the answers they provide are accurate. Not easy - but vital!

David.

ps I would love to know what trials the Government is undertaking on coding..SNOMED CT I know about - years off - so do you know more?

zeeclor said...

The NPCC http://www.npcc.com.au/ is a program to encourage GPs to make better use of their data. They use the coding systems that are intrinsic to the individual medical application. This is Docle for the vast majority using Medical Director. (http://www.hcn.com.au).

It is not a comprehensive plan but a first step. What they are trying out is reasonable.

Aus HIT Man said...

Hi Zeeclor,

I think we may be a little at crossed purposes. What the NPCC is doing is fine. What I am on about is having interactive, point-of-care decision support as a minimum requirement for PIP payments. Its quality systems that have this functionality that make the real difference in patient safety etc.

I don't say it easy, it just should get done ASAP rather than the minimal functionality that is now required - useful though it is to some extent.

David.

Anonymous said...

David,

I follow your blog when I can and your contributions to GPCG talk List, however, I've got to make some comments about this article.

Factual problems: You've omitted the security co-ordinator manual and training from the article. It's the biggest single task in the new PIP IM&T incentives. You've also forgotten the tax issues relating to PIP, as it is subject to their marginal tax rate.

Understanding problem: Your analysis of the cost is based around the notions of a do-it-yourself GP who sets up an absolutely minimal system without regard to proper security, or maintenance. Lots of practices did this back in 1999 when PIP IM&T started with Windows 98.

The game has moved on a lot, because GPs are being expected to do a lot more, thorough chronic disease management and other things besides PIP. More importantly, the technical and security environment has changed significantly, due to the greater expectations of use, the adoption of broadband connectivity, Microsoft's vulnerabilities and the more recently, enterprise-grade database technologies the software is moving to. Oh, plus the crappy local development environment.

The GPCG security project in 2004 was a response to Matthew Rose's study of ACT GPs, which basically showed that practice computing was about as secure and viable as a 14 y.o. with a broadband connection to his bedroom computer.

Lots of practices' set-ups are still like that and the main reason is that GPs were encouraged to computerise through the very simple incentives that you outline, and with 18-months Division support in most cases. Michael Wooldridge took the initial uptake to mean the job was done, and most Divisions stopped providing and support for their members in the IM&T arena in 2001, and did NSW's SBO.

The folly of that position is becoming clear as Divisions start to become aware of what DNIMP will mean to them.

My point is that for practices to run their computer systems in the ways that the RACGP 3rd edition standards intend they should, and that their indemnity organisation would like, is expensive. Hands up any practice whose sent it's security co-ordinator off to proper, professional training!

Let alone practices participating in the sorts of plans government asserts it has in terms of Healthconnect. Our AHS wouldn't look at electronic links to practices, because of their low-grade infrastructure and the security issues they pose.

I provide technical support to practices privately and train and run an IM Help desk in my Division role, and from my experience I would assert that the skill levels and awareness of security of most GPs, even the dedicated ones, leaves lots to be desired. Practices are expected to do too many things and participate in too many programs. As one GP said to me: "They expect us to be experts at everything". She was right, and that includes managing their practice computer system.

Not government, nor the college, nor the GPCG has been prepared to look at the real costs of doing robust, secure, skilful IT across the whole GP sector. DoHA would never countenance the sorts of do-it-yourself approach to its own IT infrastructure that it happily supports through the PIP.

Sadly, while the GPCG has contributed to the GP IT scene, it has mainly been a group of enthusiastic amateurs, whose enthusiasm has often not allowed them to see things from the perspective of the less interested majority of their profession.

As an example, I've had to train quite a few GPs how to enter allergies and past history, and help practices write their security manuals, even though they've been using MD since 1999 and we've run a training program through the past eight years. Some GPs have done very well, and made computerisation work for them, but many more struggle and remain ignorant of many of the basics.

Can the PIP fix this? Not on its own. Will it cost a lot more money for practices to do it properly? I believe it will.

Greg