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Quote Of The Year - Paul Shetler - "Its not Your Health Record it's a Government Record Of Your Health Information"

Tuesday, July 01, 2008

It is Not Clear Federal Health Minister Nicola Roxon Knows What She is Doing!

I am not sure if the readers of this blog have appreciated yet just what a fundamental change in our Primary Health Care delivery system is being proposed by the new Health Minister. While I have no strong feelings about the proposals I think it is vital they be carefully thought through.

In Australia, the UK, Canada and NZ at present primary care doctors have a very substantial ‘access control’ or gatekeeper function to the rest of the services provided by the health system (especially specialist care, investigations, non-urgent hospital care and allied health services especially). The objective of this approach is to try and ensure ant presenting clinical issue receives an appropriate clinical diagnosis and assessment before the patient is sent on for additional care. Overall the system seems to work pretty well although it is easy to identify occasions when medical involvement in accessing of care may be seen as un-necessary (e.g. physio for minor sports injuries and even –as is done overseas, the management of normal pregnancy).

However, with the gradual reduction in the number of GPs – especially outside the major metropolitan areas – clearly access to GP care for diagnosis and referral has become more difficult – and in some situations borders on the impossible.

What to do – to improve access and to reduce waiting to access care? Options include the use of more practice nurses, development of upgraded nurse practitioners, more use of midwives, train more GPs or dilution of the ‘gate-keeper’ function among others (e.g. super clinics etc).

In deciding what to do we need to be very sure we do not ‘throw the baby out with the bath water’. It is of note that, just as we are having this discussion we see in the USA there is an increasing view of the importance of that function.

AHIP Lists Medical Home Principles

The board of America’s Health Insurance Plans, the trade association for health insurers, has endorsed core principles for development of the “medical home” model, including liberal use of information technologies.

Under the medical home model, physician practices are redesigned to be more functional and workflow-friendly, and new processes are developed to focus on quality, safety and alternative reimbursement methods. The care model also calls for adoption of electronic health records, e-prescribing, clinical decision support, secure messaging and Web portal software to facilitate coordination of care among various providers.

More here:

http://www.healthdatamanagement.com/news/medical_home26529-1.html?ET=healthdatamanagement:e489:100325a:&st=email&portal=group_practices

Details of the principles can be found here:

http://www.ahip.org/content/default.aspx?bc=31|44|23691

The third paragraph makes it clear what is intended as ideal with an emphasis on holistic care delivery and a long term co-ordination of care role – supported by technology and allied health staff.

The associated press release makes the emphasis clear

“The patient-centered medical home would replace episodic care with a sustained relationship between patient and physician. This approach redesigns the care delivery model by assessing the level of illness or disease based on sound medical evidence; promoting coordination of care; and improving accountability for outcomes, patient experience, and utilization of services.

While there is current market experimentation going on to determine the appropriate structure for a medical home, the AHIP Board collaborated with other stakeholders to advance a model that focuses on the following:

  • Practice redesign so care is delivered in response to a patient’s needs and preferences;
  • Clear criteria for patient participation;
  • Adoption of health information technology to facilitate evidence-based integrated care;
  • Accountability;
  • Engaging and educating consumers and improving personal responsibility and behavior;
  • Structuring payment to align with measurable improvements; and
  • Pilot testing before moving forward with reformed payment models or practice redesign.”

Now the AHIP is not some fringe group – their tag line is “Providing Health Benefits for Over 200 Million Americans.”!

With the US having been the archetypal example of a ‘gatekeeper-less’ health system one is forced to wonder if they know something the Minister has not yet caught up with?

I am not sure what the right answer is in all this but I am sure I don’t want a system that is working quite well changed without very careful consideration of all the options – including the use of more Health IT – and I certainly don’t want change triggered because of the current stridency of the AMA. That would be very sad!

If we change all these roles and responsibilities we need to be sure it will be for the better.

David.

7 comments:

Anonymous said...

Super clinics are fine and dandy, as long as your local member is a member of the labour party.

But, perhaps we need to supplement this with what the Danes did? They paid their GPs (and obviously their practice nurses as well) to answer patient phone calls and answer patient emails for one hour every morning.

During that hour the people with sports injuries were sent to the physio, those who needed repeat scripts had them placed in the mail, those with non-significant test result which didn't need additional follow up were told not to bother coming in, and the ones with colds and flus were told to take 2 panadols and call back the next morning.

The net result is these patients got out of the waiting room to allow other more complex patients to be dealt with during the day.

Anonymous said...

Perhaps you could have worded that a little better.

It is not clear the Federal Health Minister Nicola Roxon doesn’t know what she is doing.

OR DELETING THE DOUBLE NEGATIVES -

It is clear the Federal Health Minister does know what she is doing.

Nicola Roxon has identified many of the major deficiencies in the nation’s health system and she has set in train various enquiries, commissions, taskforces, consultancies - call them what you will - to gather information and analyse the problems and issues and make recommendations on how they should be addressed. A very sensible approach.

She has raised the bar by making some very pertinent correct observations; something no previous Health Minister has had the courage to do. Two of which come to mind are:

1. the toxic debilitating turf wars must stop before meaningful progress can be made

2. primary care has been left to develop in a piecemeal way and there is no overall strategy in place to guide us all on how to get to where we need to be.

These two point alone provide a very strong pointer to the fact that Federal Health Minister Nicola Roxon does know what she is doing. However, it is too early to say whether or not she can deliver, and whether or not she can overcome the formidable obstacles which can so easily derail so much of the reform process.

But one thing is certain she does see the problems and she is trying to address them. She deserves every support she can get.

Aus HIT Man said...

Sorry, I didn't write a double negative and I am not sure she understands the possible risks of this proposed set of changes. It would be nice to see the evidence that backs radical change vs incremental improvement.

David.

Anonymous said...

And it is not clear he does not know what she is doing.

You did not use a double negative. and I did not say that you did.

Ahh - the evidence. Where would you suggest we might find the relevant definitive evidence that backs radical change versus incremental change and vice versa?

Aus HIT Man said...

On evidence..the global comparisons of cost effectiveness, quality and safety of different models around the world might be a good start. Health Affairs Journal(probably the best health policy journal in the world) has lots on all of this.

On clarity - my topic heading was quite clear - and expressed the concern I have that this might be an ideological rather than an evidence based set of proposals - given the current spat with the AMA(or possibly just under researched to date). I just don't know.

David.

Anonymous said...

I hope Nicola Roxon's energetic burst to 'fix' the health system (some call it Reform) does not peter out the way Hilary Clinton's did when Bill assumed the Presidency.

Major health reform is frightfully difficult to achieve. One way of attacking the problem is to create disruptive chaos (the chaos theory of management) throw lots of balls up in the air and force them to coalesce differently when they come down. At the same time dismantle a few sacred cows - chop them off at the legs or open up other avenues of access. That will help drive the coalescing of balls into quite different models. If the Minister were the CEO of a large company which was sick - she would need to reorg, downsize, and rebuild to effect meaningful change. People are so resistant to change. That is no reason why change should not be made. Everyone wants to protect their turf and block any change which threatens that turf. For example - don't give anyone except the doctors access to the MBS; don't give anyone except doctors prescribing rights under the PBS; don't let pharmacies into supermarkets; don't introduce SuperClinics; don't do anything to disrupt the comfortable status quo.

Change is scary - more so in a system as complex and as politically sensitive as health. But let's face it - change is needed - so be it.

Anonymous said...

You are so right. And change we are in for; like it or not.

So everyone should get prepared and think ahead - think longterm and strategically. And those who are really smart will go with the flow to make sure they are positioned ahead of 'the others' so they can have some impact on 'how the next round of turf wars will be orchestrated. In primary care the doctors are the most vulnerable, disorgansised and fragmented of the major players so they are probably the most vulnerable to getting rolled.